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 D
Explanation
A. Hands should be washed with warm water, not hot, to prevent skin irritation.
B. The recommended handwashing duration is at least 20 seconds.
C. The faucet should be turned off using a paper towel or elbow to avoid recontamination.
D. Holding hands below the elbows allows water to flow downward, preventing contamination from the elbows back onto the hands.
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.
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