A 40-year-old female patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on which one of the following?
Cool, clammy skin.
BP of 82/40 mm Hg.
Heart rate of 48 beats/min.
Shortness of breath.
The Correct Answer is C
Neurogenic shock is a type of distributive shock that occurs due to the loss of sympathetic nervous system tone after a spinal cord injury or other traumatic brain injuries. This loss of sympathetic tone leads to vasodilation and decreased systemic vascular resistance, resulting in inadequate perfusion to vital organs.
One of the hallmark signs of neurogenic shock is bradycardia (a heart rate less than 60 beats/min) due to the unopposed parasympathetic activity. The parasympathetic system becomes dominant when sympathetic activity is impaired. Therefore, a heart rate of 48 beats/min in this patient suggests the possibility of neurogenic shock.
A. Cool, clammy skin in (option A) is incorrect because Cool, clammy skin is a characteristic of hypovolemic shock, where reduced blood volume leads to vasoconstriction to redirect blood flow to vital organs.
B. BP of 82/40 mm Hg in (option B) is incorrect because: Hypotension is a common finding in both neurogenic shock and hypovolemic shock. A low blood pressure reading alone does not specifically indicate neurogenic shock.
D. Shortness of breath in (option D) is incorrect because Shortness of breath is not specific to neurogenic shock but can occur in various types of shock, including hypovolemic shock. It may result from inadequate oxygenation or impaired respiratory function due to the underlying condition or associated injuries.
Therefore, the heart rate of 48 beats/min suggests the possibility of neurogenic shock in addition to hypovolemic shock in this patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Disseminated Intravascular Coagulation (DIC) is a condition characterized by widespread activation of the coagulation system, leading to both excessive clot formation and consumption of clotting factors and platelets. This process can result in both bleeding and thrombosis.
The manifestations mentioned in option B are commonly seen in DIC:
Decreased platelet counts: DIC leads to platelet consumption and destruction, resulting in low platelet counts (thrombocytopenia).
Increased D-dimer: D-dimer is a fibrin degradation product, and its levels are increased DIC due to the breakdown of fibrin clots.
Increased prothrombin time (PT): DIC can lead to the depletion of clotting factors, resulting in prolonged prothrombin time, indicating impaired coagulation.
The other options mentioned do not represent the typical clinical manifestations of DIC:
A. Decreased hematocrit, increased platelet counts, and increased D-dimer in (option A) are incorrect because While platelet counts and D-dimer are increased in DIC, decreased hematocrit is not a characteristic finding.
C. Decreased Antithrombin III, increased platelet counts, and increased fibrinogen in (option C) is incorrect because: Decreased Antithrombin III can be seen in DIC, but increased platelet counts and fibrinogen levels are not specific to DIC.
D. Decreased D-dimer, increased platelet counts, and increased hemoglobin in (option D) is incorrect because Decreased D-dimer and increased hemoglobin are not typical findings in DIC, while increased platelet counts can be seen in some cases.
Correct Answer is C
Explanation
This method, known as the 6-second method, involves counting the number of QRS complexes in a 6-second interval on the electrocardiogram (ECG) strip and then multiplying that number by 10 to calculate the heart rate per minute. The advantage of this method is that it provides a relatively quick estimate of the heart rate.
A. Printing a 1-minute ECG strip and counting the number of QRS complexes in (option A) is incorrect because it can be time-consuming and may not be practical in situations where a quick estimate is needed.
B. Calculating the number of small squares between one QRS complex and the next and dividing into 1500 in (option B) is incorrect because it is a method used to calculate heart rate, known as the "1500 method," but it is not as quick as the 6-second method and requires more time and measurement precision.
D. Counting the number of large squares in the R-R interval and dividing by 300 is another method used to calculate heart rate, known as the "300 method," but it is also less quick and less accurate for assessing heart rate in patients with regular rhythms.
It's important to note that if the heart rhythm is irregular, these methods may not provide an accurate estimate of the heart rate, and a longer monitoring period or a different approach may be necessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today