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. A murmur and splinter hemorrhages are expected findings in infective endocarditis and do not indicate an immediate life-threatening condition.
B. Sharp chest pain with inspiration in rheumatic fever may indicate pericarditis, which needs monitoring but is not immediately unstable.
C. Bilateral crackles suggest fluid overload in dilated cardiomyopathy, requiring attention, but not as urgent as hypotension in acute valve failure.
D. Acute aortic regurgitation with hypotension (BP 86/54 mm Hg) indicates a possible hemodynamic collapse and cardiogenic shock, making this client the highest priority for immediate assessment and intervention.
Correct Answer is C
Explanation
A. Sinus bradycardia is characterized by a heart rate less than 60 beats/min, but in this case the rate is exactly 60, which is normal lower limit.
B. First degree heart block involves a prolonged PR interval (>0.20 seconds); here, the PR interval is normal (0.16 seconds).
C. Normal sinus rhythm has regular P waves and QRS complexes, a normal PR interval (0.12–0.20 seconds), and a heart rate between 60–100 beats/min.
D. Sick sinus syndrome is characterized by irregular rhythms and abnormal sinus node function, which is not indicated here.
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