A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?
The client who has chronic kidney disease
The client experiencing an asthma attack
The client who has Guillain-Barré syndrome
The client who has a severe burn injury
The Correct Answer is C
A. This client is at risk for other complications such as electrolyte imbalances or heart failure, but not specifically neurogenic shock.
B. This client is experiencing respiratory distress, which is a different type of shock (anaphylactic or septic shock might be considered, but not neurogenic).
C. Guillain-Barré syndrome is an autoimmune disorder that affects the nervous system, often leading to paralysis. It can cause a rapid loss of muscle function, which can result in neurogenic shock due to loss of sympathetic nervous system tone.
D. This client is at risk for hypovolemic shock due to fluid loss, not neurogenic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atrial fibrillation is consistent with the symptoms described. It causes irregular palpitations and dizziness due to the rapid and irregular ventricular rate. The significant pulse deficit can occur because the irregular rhythm may lead to intermittent weak or absent pulses. The ECG typically shows an irregular rhythm with no identifiable P waves and an irregularly irregular ventricular response.
B. Sinus bradycardia does not usually cause a rapid and irregular heart rate. It is characterized by a regular rhythm with a slow heart rate. While it can cause fatigue and dizziness, it does not typically present with an irregular rhythm or a significant pulse deficit. Therefore, it is less consistent with the symptoms described.
C. Sinus tachycardia is characterized by a rapid but regular heart rate. It does not typically present with an irregular rhythm or significant pulse deficit. While it may cause symptoms such as palpitations and
dizziness, the regular rhythm and absence of irregularity in the ECG make it less likely to be the cause of the significant irregular pulse deficit described.
D. First-degree AV block does not usually cause a rapid and irregular heart rate. It typically presents with a regular rhythm but with a prolonged PR interval. It is not typically associated with irregular palpitations or a significant pulse deficit. The symptoms described are not characteristic of first-degree AV block.
Correct Answer is B
Explanation
A. A high CVP, not a low CVP, is typically associated with fluid overload.
B. A low CVP indicates decreased fluid volume, which is characteristic of hypovolemia. This is particularly relevant to a patient with multiple traumas who may have significant blood loss.
C. While left ventricular failure can contribute to hemodynamic instability, it's not directly correlated with a low CVP.
D. This would affect the oxygenation status of the blood, rather than the overall blood volume and CVP.
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