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

Answer 1

During the early decompensation stage of shock, nurses should report significant changes in urine output, skin color, vital signs, and peripheral pulses, as these are critical assessments that reflect the client's circulatory status.

Step-by-step explanation:

The nurse caring for a client diagnosed with shock should report the early signs of the decompensation stage during the report, which include:

• Urine output: A significant drop in urine output, specifically less than 1 mL/kg body weight/hour, is a concerning sign of decompensating shock.
• Skin color: Changes such as pallor or a cool, clammy touch, particularly in the extremities, are indicative of restricted peripheral blood flow.
• Vital signs: These include an increased heart rate but decreased blood pressure, or even normal blood pressure in some cases. Patients may also exhibit rapid, shallow breathing.
• Peripheral pulses: A weak or thready pulse can signal poor blood perfusion, also found in states of shock.

Other options such as gait and nutrition are less relevant to the immediate physiological changes occurring in shock and are thus less indicative of the early decompensation stage. The nurse should focus on the most critical assessments that indicate the client's circulatory status.