Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
a. Thirst
b. Irritability
c. Apprehension
d. Confusion and somnolence
ANS: D
Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
You might also like to view...
A community health nurse is responding to a disaster. Which of the following would most likely be the least appropriate area for the nurse to be?
A) The disaster site B) Triage C) Victim treatment area D) Local hospitals
How should the nurse document a patient's chief complaint of right hip pain for the comprehensive health history?
A) Patient complains of right hip pain. B) Patient states right hip hurts with walking. C) "I have pain in my right hip when I walk." D) "I am here to see a doctor for pain."
The nurse observes that the patient's left cephalic intravenous (IV) site is cool, swollen, and mildly tender, although the IV line is infusing at the prescribed rate. Which action should the nurse take first?
a. Instruct the patient to elevate his or her arm on two pillows. b. Discontinue the IV infusion and start one in the right arm. c. Apply a warm, moist compress to the IV site. d. Reassess the IV site in 2 hours for any change.
While providing surgical wound care on a patient recovering from abdominal surgery, the nurse notes a new onset of green-brown drainage on the dressing that appears to be seeping between the sutures
Which of the following should the nurse do to help this patient? 1. clean the wound and apply a new dressing 2. clean the wound and keep it open to air 3. prepare to have the surgical staples removed since this draining indicates healing 4. immediately notify the physician