Nursing assessment of early evidence of septic shock in children at risk includes:

• A.Fever, tachycardia, and tachypnea
• B.Respiratory distress, cold skin, and pale extremities
• C.Elevated blood pressure, hyperventilation, and thready pulses
• D.Normal pulses, hypotension, and oliguria

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When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

• A.In neurogenic shock, the skin is warm and dry
• B.In hypovolemic shock, there is a bradycardia
• C.In hypovolemic shock, capillary refill is less than 2 seconds
• D.In neurogenic shock, there is delayed capillary refill

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Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?

• A.Heterozygotes are affected.
• B.The disorder is always carried on the X chromosome.
• C.Only females are affected.
• D.Two affected parents always have affected children.

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A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything about me. It's people like you who let my baby die." The nurse's best course of action is to:

• A.Quietly leave her room, allowing her more private time to deal with her loss.
• B.Tell her that what happened was for the best and that she is still young and can have other children.
• C.Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
• D.Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.

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A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?

• A.Assure her that this is most likely the result of bladder spasms.
• B.Check the collection bag and tubing to verify that the catheter is draining properly.
• C.Instruct her to do Kegel exercises to diminish the urge to void.
• D.Ask her if she has felt this way before.

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