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 D
Explanation
A. Scarring of the mitral valve is typically associated with rheumatic heart disease, not pericarditis.
B. Deformity of the valve leaflets is seen in valvular heart diseases, not pericarditis.
C. Inflammation of the endocardium refers to endocarditis, a different condition from pericarditis.
D. Pericardial effusion, the accumulation of fluid in the pericardial sac, is a common complication of pericarditis and can lead to cardiac tamponade if not managed.
Correct Answer is B
Explanation
A. Blood flowing back from the left atrium to the left ventricle describes mitral regurgitation, not aortic regurgitation.
B. Aortic regurgitation involves the backflow of blood from the aorta into the left ventricle during diastole due to an incompetent aortic valve. This leads to volume overload in the left ventricle.
C. Obstruction of blood from the left atrium to the left ventricle occurs in mitral stenosis, not aortic regurgitation.
D. Obstruction of blood flow from the left ventricle is characteristic of aortic stenosis, not aortic regurgitation.
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