A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?
a. Restlessness
b. Rapid capillary refill
c. Increased temperature
d. Increased blood pressure
ANS: A
Restlessness is an indication of impending shock in a child. Capillary refill is slowed in shock. The child will feel cool. The blood pressure initially remains within the normal range and then declines.
You might also like to view...
A pediatric nurse examines a 7-year-old girl at a well-child visit. The nurse is aware that this child is in Erickson's Accomplishment/Industry vs. Inferiority Stage and that the basic task of this stage is to:
A) recognize that there are people in her life (parents) who can be trusted to take care of her basic needs. B) balance independence and self-sufficiency against the predictable sense of uncertainty and misgiving when placed in life's situations. C) develop resourcefulness to achieve and learn new things without receiving self-reproach. D) develop a sense of confidence through mastery of tasks.
A client's insulin is administered at 7:00 AM daily. The client is to receive regular and NPH (Humulin N) insulins. The nurse is teaching the client how to prepare the syringe before injection
In preparing the syringe, the client should be taught to: a. withdraw each medication in a separate syringe. b. draw up regular insulin first. c. draw up NPH insulin first. d. recognize that order of medication withdrawal is not a priority.
A client who is receiving chemotherapy frequently complains of headache. The most effective nursing intervention would be to administer:
1. ibuprofen. 2. naproxen. 3. aspirin. 4. acetaminophen.
A nurse has performed a physical examination of the patient and reviewed the laboratory and diagnostic test results on the patient's chart. The nurse is performing which specific nursing function?
A. Diagnosis B. Assessment C. Education D. Advocacy