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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Anaphylactic shock is a life-threatening allergic reaction, but it is less common and less frequently the cause of ICU deaths compared to septic shock.
B. Neurogenic shock results from spinal cord injuries or central nervous system damage and is relatively rare.
C. Septic shock is the most common cause of death in intensive care units in the United States. It results from overwhelming infection and leads to systemic inflammation, vasodilation, and multi-organ dysfunction.
D. Cardiogenic shock occurs due to the heart’s inability to pump effectively, often after a major myocardial infarction, but it is not the leading cause of death in ICUs.
Correct Answer is D
Explanation
A. Sinus bradycardia is characterized by a heart rate below 60 beats/min, which is inconsistent with this client’s elevated heart rate of 128.
B. Ventricular tachycardia is a potentially life-threatening rhythm with wide QRS complexes, usually not the immediate expected rhythm without other signs such as hypotension or loss of consciousness.
C. Normal sinus rhythm has a heart rate between 60–100 beats/min; this client’s rate of 128 exceeds that range.
D. Sinus tachycardia is the most likely rhythm, especially in a client who has used cocaine, a stimulant known to increase sympathetic nervous system activity, leading to increased heart rate and elevated blood pressure.
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