A client with chronic pain is using aspirin regularly to control her pain symptoms. She presents to the hospital with abdominal pain, pale skin, afebrile, and a blood pressure (BP) of 83/45 mm Hg. Which type of shock is the client most likely experiencing?

Hypovolemic shock

Obstructive shock

Cardiogenic shock

Septic shock

Answer and Explanation

The Correct Answer is A

A. Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.
B. Obstructive shock is due to a physical obstruction of blood flow, such as a pulmonary embolism or cardiac tamponade, which does not directly correlate with the client's presentation of symptoms.
C. Cardiogenic shock results from severe heart failure and is typically accompanied by signs of heart dysfunction, not just low blood pressure and abdominal pain.
D. Septic shock is associated with infection and systemic inflammation, often presenting with fever and other signs of infection, which the client is not exhibiting.

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Correct Answer is A

Explanation

A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is crucial for managing SLE and preventing flare-ups. This demonstrates the client's understanding of the importance of medication adherence.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is known to exacerbate SLE. This statement reflects an understanding of the need to reduce stress to manage the disease effectively.
D. Wearing protective clothing when going outside is essential to prevent sun exposure, which can trigger SLE flare-ups. This indicates that the client understands the need for sun protection.

A. Glucose at 1130 B. Client report of shakiness C. Temperature D. Heart rate E. SPO2 F. HbA1c

Correct Answer is ["A","B","D"]

Explanation

A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.

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A client with chronic pain is using aspirin regularly to control her pain symptoms. She presents to the hospital with abdominal pain, pale skin, afebrile, and a blood pressure (BP) of 83/45 mm Hg. Which type of shock is the client most likely experiencing?

Nursing Test Bank

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