Author Question: Which clinical manifestations would the nurse expect to see as shock progresses in a child and ... (Read 127 times)

jazziefee · **on:** Jun 28, 2018

Which clinical manifestations would the nurse expect to see as shock progresses in a child and becomes decompensated shock (Select all that apply)?

a. Thirst and diminished urinary output
b. Irritability and apprehension
c. Cool extremities and decreased skin turgor
d. Confusion and somnolence
e. Normal blood pressure and narrowing pulse pressure
f. Tachypnea and poor capillary refill time

Question 2

The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands?

a. Organize nursing activities to allow for uninterrupted sleep.
b. Allow the infant to sleep through feedings during the night.
c. Wait for the infant to cry to show definite signs of hunger.
d. Discourage parents from rocking the infant

blakeserpa · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C, D, F
Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock.

Answer to Question 2

ANS: A
The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant's sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful.