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
In this scenario, the patient's signs and symptoms suggest a state of shock, which can be caused by various factors, such as hypovolemia, cardiac dysfunction, or systemic vasodilation. The first priority in managing a patient in shock is to ensure adequate oxygenation and tissue perfusion. Administering oxygen at 100% per non-rebreather mask helps improve oxygen delivery to the tissues and supports vital organ function.
A. Placing the patient on a continuous cardiac monitor in (option A) is incorrect because it is an important step to monitor the patient's heart rhythm and identify any abnormalities. However, providing oxygen should take priority to address the potential hypoxemia and tissue hypoperfusion.
C. Inserting two 14-gauge IV catheters in (option C) is incorrect because it is crucial for establishing large-bore access for fluid resuscitation and medication administration. While it is an important step, addressing oxygenation takes precedence.
D. Drawing blood to type and crossmatch for transfusions in (option D) is incorrect because it is an important step in managing a patient in shock who may require blood products. However, ensuring adequate oxygenation through oxygen administration is the immediate priority.
Therefore, the nurse should act first on the order to administer oxygen at 100% per non-rebreather mask to support the patient's oxygenation and tissue perfusion.
Correct Answer is D
Explanation
Arterial pressure monitoring involves the insertion of an arterial catheter, typically in the radial artery, to directly measure blood pressure. Complications can arise from this invasive procedure, and one potential complication is inadequate blood flow to the hand, leading to numbness or ischemia.
A. The Allen's test is positive in (option A) is incorrect because The Allen's test is performed before arterial catheter insertion to assess the collateral circulation of the hand. A positive Allen test indicates adequate collateral circulation, which is desirable before performing the procedure. However, it does not directly indicate a complication during or after arterial pressure monitoring.
B. The mean arterial pressure (MAP) is 90 mm Hg in (option B) is incorrect because The mean arterial pressure (MAP) represents the average pressure in the arterial system during one cardiac cycle. While changes in MAP can be significant for patient management, it does not specifically indicate a complication of arterial pressure monitoring.
C. The dicrotic notch visible in the waveform in (option C) is incorrect because The dicrotic notch represents the closure of the aortic valve and is a normal finding in arterial waveforms. Its presence does not indicate a complication.
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