A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
Oliguria
Hypertension
Bradycardia
Peripheral edema
The Correct Answer is A
A. Oliguria, or decreased urine output, is a common finding in hypovolemia due to reduced renal perfusion and decreased blood flow to the kidneys.
B. Hypertension is unlikely in hypovolemia; instead, clients typically exhibit hypotension due to decreased circulating blood volume.
C. Bradycardia is not a typical finding in hypovolemia; instead, tachycardia is more commonly observed as the body compensates for reduced blood volume.
D. Peripheral edema is associated with fluid overload rather than hypovolemia, as a decrease in blood volume usually leads to less fluid accumulation in the tissues.
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Correct Answer is B
Explanation
A. Blood pressure does not increase during anaphylaxis; instead, it typically decreases due to vasodilation and fluid leakage.
B. During anaphylaxis, blood vessels become more permeable, leading to the release of fluids into the tissues, which causes swelling and contributes to hypotension.
C. Blood vessels do not constrict during anaphylaxis; rather, they dilate as a part of the allergic response, resulting in decreased blood pressure.
D. While there is an immune response during anaphylaxis, white blood cells are not destroyed; rather, they are activated to respond to the allergen, leading to inflammation and other systemic effects.
Correct Answer is C
Explanation
A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.