A 57-year-old-client is being admitted to the intensive care unit (ICU) with a diagnosis of possible septic shock He has a normal blood pressure, increased heart rate, decreased bowel sounds, and their skin is cold and clammy. The ICU nurse suspects the client:
Will stabilize and be released by tomorrow
Is in the irreversible stage of shock
Is in the progressive stage of shock
Is in the compensatory stage of shock
The Correct Answer is C
A. A client showing signs of shock (e.g., cold, clammy skin, decreased bowel sounds, tachycardia) is not likely to stabilize and be released by the next day without intensive treatment.
B. The irreversible stage of shock is marked by profound hypotension, multi-organ failure, and unresponsiveness—more severe than this client’s current status.
C. The progressive stage of shock is characterized by impaired tissue perfusion, cold and clammy skin, tachycardia, hypoactive bowel sounds, and early signs of organ dysfunction. Even though the blood pressure is currently normal, perfusion is inadequate.
D. The compensatory stage is earlier and includes signs like tachycardia and restlessness, but perfusion to vital organs is still maintained, and skin may remain warm. This client’s cold skin and decreased bowel sounds suggest progression beyond this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Renal function – Requires follow-up: The client’s BUN is 28 mg/dL (high), and creatinine is 1.5 mg/dL (above normal range). This indicates possible renal hypoperfusion or early acute kidney injury due to decreased cardiac output from worsening heart failure. This needs immediate evaluation to prevent further decline in renal function.
B. Cardiac enzymes – Does NOT require follow-up: Troponin T = 0.06 ng/mL and Troponin I = 0.01 ng/mL, both of which are within normal limits. There is no evidence of acute myocardial infarction, so this finding does not require immediate follow-up.
C. BNP – Requires follow-up: BNP is 800 ng/mL (normal < 100 ng/mL), which is markedly elevated. This is a specific indicator of acute decompensated heart failure, requiring urgent treatment such as diuretics, oxygen, and possibly vasodilators.
D. ECG results – Requires follow-up: The client is in atrial fibrillation with rapid ventricular response (RVR) at a rate of 135/min. This rhythm can reduce cardiac output and increase risk for thromboembolic events. It requires rate control or rhythm conversion and anticoagulation evaluation.
E. Neurologic status – Does NOT require follow-up: The client is alert and oriented ×3, follows commands, and has no neurological deficits. This indicates no current neurologic impairment, so this finding is stable and does not need immediate intervention.
Correct Answer is C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
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