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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:

A.

Will stabilize and be released by tomorrow

B.

Is in the irreversible stage of shock

C.

Is in the progressive stage of shock

D.

Is in the compensatory stage of shock

Answer and Explanation

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.
 


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Related Questions

Correct Answer is D

Explanation

A. Class I: No limitation of physical activity; ordinary activity does not cause symptoms. This client clearly experiences symptoms with ordinary activities.
B. Class II: Slight limitation of physical activity; comfortable at rest, but ordinary activity causes fatigue, dyspnea, or chest pain. This client is more limited than Class II.
C. Class IV: Unable to carry out any physical activity without discomfort; symptoms may be present even at rest. This client does not have symptoms at rest.
D. Class III: Marked limitation of physical activity; comfortable at rest, but less-than-ordinary activity (e.g., brushing teeth, walking to the bathroom) causes fatigue, dyspnea, or chest pain. This best fits the client's condition.

Correct Answer is A

Explanation

A. This is the correct sequence of normal electrical conduction through the heart: the impulse originates in the sinoatrial (SA) node, travels to the atrioventricular (AV) node, then to the bundle of His, down the right and left bundle branches, and finally through the Purkinje fibers.
B. This choice places the Purkinje fibers before the bundle branches, which is incorrect.
C. The AV node does not initiate conduction; the SA node is the natural pacemaker of the heart.
D. This sequence incorrectly places the bundle branches before the bundle of His.

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