Complete the following sentence with one of the options regarding the pathophysiology of this type of shock.
The nurse is caring for an elderly patient from a nursing home diagnosed with a urinary tract infection. The nurse assesses the patient as hypotensive, tachycardic, febrile, tachypneic, and with an altered mental status. The nurse understands that the pathophysiology of this type of shock is caused by___
Massive blood loss leading to decreased oxygen delivery to tissues
Severe allergic reaction causing systemic vasodilation and increased capillary permeability
Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion
Cardiac failure resulting in inadequate tissue perfusion and oxygenation
The Correct Answer is C
A. Massive blood loss leading to decreased oxygen delivery to tissues
This describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.
B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability
This describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.
C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion
This patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.
D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation
This describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.
B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.
C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.
D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.
Correct Answer is B
Explanation
A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
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