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 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.
Correct Answer is D
Explanation
A. Mitral valve prolapse often requires no treatment or is managed with medications; balloon valvuloplasty is not typically used.
B. Aortic regurgitation usually requires surgical valve replacement rather than valvuloplasty.
C. Mitral regurgitation involves backward blood flow and is generally treated with valve repair or replacement, not balloon valvuloplasty.
D. Mitral stenosis is most commonly treated with balloon valvuloplasty, especially in clients with rheumatic heart disease. This procedure helps open a narrowed mitral valve by inflating a balloon within the valve to improve blood flow.
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