A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?
The client has metabolic alkalosis and warm extremities
The client develops bradycardia and bradypnea
The client has hypotension and is confused
The client has hypertension and anuria
The Correct Answer is C
A. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically indicative of postoperative shock. Metabolic alkalosis may be caused by excessive vomiting or prolonged gastric suctioning, but it is not a hallmark sign of shock. Warm extremities may suggest adequate peripheral perfusion rather than impaired perfusion seen in shock.
B. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) may occur as compensatory mechanisms in certain types of shock, such as neurogenic shock. However, they are not specific indicators of postoperative shock. Tachycardia (rapid heart rate) and tachypnea (rapid respiratory rate) are more common findings in most types of shock, including postoperative shock.
C. The client has hypotension and is confused: Hypotension (low blood pressure) and confusion are classic signs of shock, including postoperative shock. Hypotension indicates inadequate perfusion of vital organs, while confusion may result from cerebral hypoperfusion. Altered mental status, such as confusion, is a significant neurological manifestation of shock.
D. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (decreased urine output) are not typical manifestations of postoperative shock. Hypertension may occur in certain conditions that can lead to shock, such as septic shock, during the compensatory phase. However, it is not a primary sign of shock. Anuria may occur in cases of severe hypovolemic shock but is not specific to postoperative shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
All of the following should be included in the teaching:
A. Living a sedentary lifestyle: Sedentary behavior, characterized by physical inactivity, is a risk factor for various cardiovascular conditions, including atrial fibrillation. Regular exercise is important for maintaining heart health and reducing the risk of atrial fibrillation.
B. Family history of atrial fibrillation: A family history of atrial fibrillation increases an individual's risk of developing the condition. Genetic factors play a role in predisposing individuals to atrial fibrillation, and having a close relative with the condition can elevate one's risk.
C. History of thyroid disease: Thyroid disorders, particularly hyperthyroidism (overactive thyroid), are associated with an increased risk of atrial fibrillation. Thyroid hormones influence heart rate and rhythm, and imbalances can predispose individuals to atrial fibrillation.
D. Recent influenza infection: Infections, particularly respiratory infections such as influenza, can trigger episodes of atrial fibrillation in susceptible individuals. The inflammatory response and physiological stress associated with infections can disrupt normal heart rhythm and precipitate atrial fibrillation episodes.
Correct Answer is D
Explanation
A. White blood cell level of 5,900 mm3: While abnormal white blood cell levels can indicate infection or inflammation, they are not typically associated with directly contributing to an episode of delirium. However, underlying conditions that cause abnormal white blood cell levels, such as infection or inflammation, may contribute to delirium.
B. Potassium level of 4.1 mEq/L: Potassium imbalances can lead to various neurological symptoms, including weakness, paralysis, and cardiac arrhythmias. However, a potassium level of 4.1 mEq/L is within the normal range and is unlikely to directly contribute to an episode of delirium.
C. Hemoglobin level of 14.2 g/dL: Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are not directly associated with delirium. While severe anemia or hypoxia can cause neurological symptoms, a hemoglobin level of 14.2 g/dL is within the normal range and is unlikely to directly contribute to delirium.
D. Blood glucose level of 254 mg/dL: Elevated blood glucose levels, as indicated by a blood glucose level of 254 mg/dL, can contribute to an episode of delirium. Hyperglycemia can lead to alterations in cerebral metabolism, neuronal dysfunction, and impaired cognitive function, predisposing individuals to delirium. Additionally, hyperglycemia can exacerbate preexisting neurological conditions and increase the risk of developing delirium in critically ill patients. Therefore, monitoring and managing blood glucose levels are essential in preventing and managing delirium in hospitalized patients.
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