A nurse is assessing a postoperative client who is at risk for internal hemorrhage. Which of the following clinical findings should the nurse identify as the earliest indicator of developing hypovolemic shock?
- Unexplained restlessness and an increasing heart rateCevap
- BA significant decrease in systolic blood pressure
- CUrine output dropping to less than 30 mL per hour
- DDevelopment of slow, shallow respirations
Cevap
The earliest indicator of developing hypovolemic shock is unexplained restlessness and an increasing heart rate.
The correct answer identifies that sympathetic nervous system activation in early shock causes an increased heart rate (tachycardia) and changes in mental status, such as restlessness or mild anxiety. These are the body's initial compensatory mechanisms responding to decreased circulating volume before the blood pressure ultimately drops.
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Anahtar Kavram
Early compensatory mechanisms in hypovolemic shock include tachycardia and altered mental status (such as restlessness or anxiety), whereas hypotension is a late sign indicating compensatory failure.