A nurse assessing a client determines they are in the compensatory stage of shock. Which of the following findings support this conclusion?

Blood pressure 84/50 mm Hg

Petechiae

Confusion

Anuria

Answer and Explanation

The Correct Answer is C

A. A blood pressure of 84/50 mm Hg is more consistent with the progressive stage of shock, where compensation is failing.
B. Petechiae may be seen in disseminated intravascular coagulation (DIC), a complication of severe shock, typically not in the compensatory stage.
C. Confusion is an early sign of impaired cerebral perfusion, which can occur in the compensatory stage of shock. It reflects the body’s efforts to maintain perfusion to vital organs despite declining cardiac output.
D. Anuria (no urine output) is a late finding, typically seen in the irreversible stage of shock, indicating complete renal failure.

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Correct Answer is B

Explanation

A. Airway: Ensure the airway is open.
B. Breathing: Provide rescue breaths if the person is not breathing.
C. Circulation: Begin chest compressions to maintain blood flow.
D. Defibrillation: Use an automated external defibrillator (AED) as soon as it's available, especially in cases of shockable rhythms like ventricular fibrillation.

A. Increase the head of the bed. B. Place the patient in a recovery position. C. Stop the infusion of the medication. D. Slow down the infusion of the medication.

Correct Answer is C

Explanation

A. Increasing the head of the bed may help ease breathing but does not address the potential cause of the problem.
B. The recovery position is used for unconscious patients to maintain an open airway—not appropriate here.
C. Stopping the infusion of the medication is the first and most critical action. The client is likely experiencing an allergic reaction or anaphylaxis to penicillin, and continuing the drug could worsen symptoms.
D. Slowing the infusion does not prevent further reaction and delays stopping the exposure to the allergen.

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A nurse assessing a client determines they are in the compensatory stage of shock. Which of the following findings support this conclusion?

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Naxlex Comprehensive Predictor Exams

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