A nursing instructor asks a student to identify the early signs ...

[Kikoku]

A nursing instructor asks a student to identify the early signs and symptoms of hypovolemic shock. Which response by the student would indicate to the instructor that further teaching is needed? (Select all that apply.)
 
  a. Tachycardia d. Skin cool to touch
  b. Tachypnea e. Cyanosis with cold, clammy skin
  c. Hypotension f. Urinary output less than 30 mL per hour

Question 2

An adolescent with cystic fibrosis is intubated with an endotracheal tube. Which is the most appropriate nursing diagnosis?
 
  1. Potential for imbalanced nutrition, more than body requirements related to inactivity
  2. Anxiety related to leaving chores undone at home
  3. Potential for fear of future pain related to medical procedures
  4. Powerlessness (moderate) related to inability to speak or communicate with friends

[jasonq]

Answer to Question 1

C, E, F
The instructor would recognize that further teaching is needed if the student responded hypotension; cyanosis with cold, clammy skin; and urinary output less than 30 mL per hour. These are late signs of hypovolemic shock. The early signs of hypovolemic shock include: tachycardia; tachypnea; skin cool to touch; weak peripheral pulses; and pale skin and mucous membranes.

Answer to Question 2

4
Rationale:
1. The adolescent with cystic fibrosis is likely to be underweight, and is unlikely to take in more calories than needed while intubated.
2. The adolescent is present-, not future-, oriented, and is unlikely to worry about household chores.
3. The adolescent is present-, not future-, oriented, and is unlikely to worry about future unknown procedures.
4. The adolescent values communication with peers, and might feel frustrated that she cannot speak to them while intubated.

Chapter 43_LO01

[Kikoku]

Excellent

[meganmoser117]

TYSM