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. 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.
Correct Answer is A
Explanation
A. Hepatomegaly (enlarged liver) is a classic sign of right ventricular failure due to systemic venous congestion.
B. A dry, hacking cough is more commonly associated with left-sided heart failure and pulmonary congestion.
C. Crackles in the lungs result from fluid backing up into the lungs, a hallmark of left-sided heart failure, not right-sided.
D. Dizziness may occur in left-sided failure due to decreased cardiac output and poor cerebral perfusion, but it is not a key feature of right-sided failure.
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