Physiological Adaptation Practice Question

Question

The nurse is caring for a client with shortness of breath and is focused on shock risk scenario 8. Which nursing action is most appropriate?

Answer choices

  1. A. Delay assessment until the next scheduled round if the client is not calling for help.
  2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
  3. C. Recognize hypotension, tachycardia, altered mentation, and poor perfusion.
  4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

C. Recognize hypotension, tachycardia, altered mentation, and poor perfusion.

Explanation

The priority action for shock risk is to recognize hypotension, tachycardia, altered mentation, and poor perfusion. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

  • Difficulty: medium
  • Domain: Physiological Adaptation
  • Objective: shock risk

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