A nurse is assessing a client with a temperature of 39°C (102.2°F) and a blood pressure of 90/60 mmHg. Which condition is the client most likely experiencing?
Septic shock.
Cardiogenic shock.
Neurogenic shock.
Anaphylactic shock.
The Correct Answer is A
Choice A rationale
Septic shock is a severe infection leading to systemic inflammation, characterized by high fever (39°C), low blood pressure (90/60 mmHg), and signs of organ dysfunction. It is a medical emergency requiring immediate intervention.
Choice B rationale
Cardiogenic shock is caused by the heart’s inability to pump blood effectively, leading to hypotension and signs of poor perfusion, but not necessarily high fever.
Choice C rationale
Neurogenic shock results from a disruption in the autonomic pathways, leading to hypotension and bradycardia, but not high fever.
Choice D rationale
Anaphylactic shock is a severe allergic reaction causing hypotension, respiratory distress, and other symptoms, but not typically high fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion.
These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.
Correct Answer is A
Explanation
Choice A rationale
Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.
Choice B rationale
A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.
Choice C rationale
A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.
Choice D rationale
Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.
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