Author Question: The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in ... (Read 50 times)

mmm · **on:** Jun 28, 2018

The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

a. Tachypnea
b. Oliguria
c. Confusion
d. Pale extremities
e. Hypotension
f. Thready pulse

Question 2

The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching?

a. I can alternate using a tampon and a sanitary napkin.
b. I should wash my hands before inserting a tampon.
c. I can use a superabsorbent tampon for more than 6 hours.
d. I should call my health care provider if I suddenly develop a rash that looks like sunburn.

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

Answer to Question 1

ANS: A, B, C, D
As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thready pulse are clinical manifestations of irreversible shock.

Answer to Question 2

ANS: C
Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears.