Rodrick Simpson a.k.a. "Crook", a 35-year-old gangster, was knifed in a street fight. He was admitted through the Emergency Department and is now in the ICU. An assessment of his condition reveals the following: respirations shallow and rapid, paradoxical pulse, CVP 15 cm H2O, BP 90mmHg systolic, skin cold and pale, and urinary output 60-100mL.hr for the last 2 hours. Analyzing these findings, the nurse will base a nursing diagnosis on the conclusion that the client has which one of the following conditions?

Question

Quizplus · Accepted Answer

All of the client's manifestations are found in both cardiac tamponade and hypovolemic shock except the increase in urinary output. In shock, urinary output decreases to less than 30mL/hr; thus, this is a sign that would distinguish hypovolemic shock from cardiac tamponade and from the basis for a nursing diagnosis.

Rodrick Simpson A