A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAI The graduate nurse demonstrates correct understanding when he states which of the following:

It raises cardiac output and MAP.

It causes vasoconstriction and increased MAP.

There is no direct correlation to MAP.

Lower blood volume lowers MAP.

Answer and Explanation

The Correct Answer is D

A.   Severe blood loss actually decreases blood volume, which leads to decreased cardiac output and ultimately lower MAP.
B.   While it's true that the body initially responds to blood loss by vasoconstricting to maintain blood pressure, this compensatory mechanism can only last for so long. As blood loss continues, MAP will decrease.
C.   There is no direct correlation to MAP. MAP is directly influenced by cardiac output and systemic vascular resistance (SVR). Blood volume is a major determinant of both.
D.   A decrease in blood volume leads to decreased preload, which reduces cardiac output. This, in turn, lowers MAP.

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Correct Answer is D

Explanation

The client opens his eyes in response to voice, which scores 3 on the eye-opening part of the GCS.

Since the client does not understand questions, this would likely score 1 for verbal response, indicating incomprehensible sounds.

The motor response of bringing an arm up to a trapezius squeeze is localizing pain, which would score 5.

Therefore, the nurse would document the client's GCS score as E3V1M5, which totals to 9 out of a possible 15 points.

A. Widening pulse pressure B. Pulse oximetry 96% C. Increased deep tendon reflexes D. Increased heart rate

Correct Answer is D

Explanation

A. Widening pulse pressure is typically associated with increased cardiac output, which is opposite to what happens in hypovolemic shock.
B. Pulse oximetry 96% is a normal oxygen saturation level and does not indicate shock.
C. Increased deep tendon reflexes is not a typical finding in hypovolemic shock.
D. Increased heart rate is a classic compensatory mechanism in response to decreased blood volume. The body tries to maintain blood pressure by increasing heart rate.

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A nurse who is mentoring a graduate nurse explains the correlation between severe blood loss and the effect on the client's mean arterial pressure (MAI The graduate nurse demonstrates correct understanding when he states which of the following:

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Correct Answer is D

Explanation

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is D

Explanation

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