Question

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

a) Vital signs
b) Urine output
c) Skin color
d) Gait
e) Peripheral pulses
f) Nutrition

Answer 1

Early signs of the decompensation stage in a client with shock include changes in vital signs, decreased urine output, and pale or cool skin color.

Step-by-step explanation:

In a client diagnosed with shock, early signs of the decompensation stage can be identified through specific assessments. The nurse should report the results of the following assessments that signal early signs of decompensation:

• Vital signs: Changes in blood pressure, heart rate, and respiratory rate can indicate decompensation.
• Urine output: Decreased urine output, less than 1 mL/kg body weight/hour, is a cause for concern.
• Skin color: Pale or cool skin color can be a sign of restricted peripheral blood flow.