Following 2 motor vehicle collision, an adult client is brought to the emergency department with a blood pressure of 72/50 mm Hg and a blood volume loss of approximately 40%. The nurse should plan care for this client based on which expected response to hemorrhaging?

Increased preload that results in generalized peripheral edema.

The lowered blood pressure results in a reduction of the heart rate.

Decreased preload that can lead to decreased cardiac output.

Increased peripheral resistance resulting from poor renal perfusion.

Answer and Explanation

The Correct Answer is C

A) Increased preload that results in generalized peripheral edema:

This statement is incorrect. Decreased blood volume due to hemorrhage leads to decreased preload, not increased preload. Generalized peripheral edema is more commonly associated with conditions such as heart failure or kidney disease, where fluid retention leads to increased preload.

B) The lowered blood pressure results in a reduction of the heart rate:

While it's true that a decrease in blood pressure can trigger compensatory mechanisms such as an increase in heart rate (tachycardia), the specific response mentioned in this option is not entirely accurate. The primary compensatory response to hemorrhage-induced hypotension is typically an increase in heart rate, not a reduction.

C) Decreased preload that can lead to decreased cardiac output:

Correct. With decreased blood volume (preload), there is less blood returning to the heart during diastole. This leads to decreased ventricular filling and subsequently decreased stroke volume and cardiac output. Decreased cardiac output can contribute to hypotension and inadequate tissue perfusion.

D) Increased peripheral resistance resulting from poor renal perfusion:

While poor renal perfusion can trigger mechanisms to increase peripheral resistance (such as activation of the renin-angiotensin-aldosterone system), this option does not directly address the primary effect of decreased preload on cardiac output. Increased peripheral resistance alone does not adequately compensate for decreased preload to maintain cardiac output.

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Correct Answer is D

Explanation

Pressure injuries, also known as pressure ulcers or bedsores, result from prolonged pressure on the skin, leading to tissue ischemia and damage. Early recognition of the pathophysiological processes involved in pressure injury development is crucial for prevention and timely intervention. Here's why option D is the correct choice:

A) Epidermal fragility and skin excoriation with serous drainage:

This description more closely aligns with the characteristics of a superficial wound or abrasion rather than the early stages of a pressure injury. In pressure injuries, epidermal breakdown may occur later in the process, after prolonged pressure and tissue ischemia.

B) Hypodermal fluid accumulation and blister formation:

While fluid accumulation and blister formation can occur in some types of wounds, such as friction blisters or burns, they are not typically characteristic of the early stages of pressure injury development. Pressure injuries primarily involve tissue ischemia and damage due to pressure and shear forces.

C) Necrotic tissue, purulent exudate, and eschar formation:

This description is more indicative of advanced or severe pressure injuries rather than the early stages. Necrotic tissue, purulent exudate, and eschar formation typically occur in pressure injuries that have progressed to deeper tissue involvement and infection.

D) Ischemic inflammatory response marked by erythemic skin:

Correct. In the early stages of pressure injury development, the affected area may exhibit signs of tissue ischemia and inflammation, which can manifest as erythema (redness) of the skin. This erythema is a result of the body's inflammatory response to tissue damage caused by pressure and may indicate the need for intervention to relieve pressure and prevent further injury.

A. Deposition of crystals in the synovial space of the joints produces inflammation and irritation. B. Chondrocyte injury destroys joint cartilage, producing osteophytes and joint inflammation. C. An immune complex and autoantibody deposition in connective tissue results in inflammation. D. An autoimmune inflammation involving IgG response to an antigen causes joint destruction.

Correct Answer is A

Explanation

Gout is a form of inflammatory arthritis characterized by sudden, severe attacks of pain, redness, and swelling in the joints, commonly affecting the big toe joint (first metatarsophalangeal joint). The primary pathophysiological process underlying gout involves the deposition of monosodium urate crystals in the joints and surrounding tissues. Here's an explanation of why option A is the correct answer:

A) Deposition of crystals in the synovial space of the joints produces inflammation and irritation:

Correct. Elevated levels of uric acid in the blood can lead to the formation of monosodium urate crystals, which then accumulate in the synovial fluid of joints, particularly in the big toe joint in many cases. These crystals trigger an inflammatory response, activating immune cells and causing swelling, redness, warmth, and severe pain in the affected joint. The inflammation and irritation result from the body's response to the presence of these crystals.

B) Chondrocyte injury destroys joint cartilage, producing osteophytes and joint inflammation:

This option describes a process more characteristic of osteoarthritis, where degeneration of joint cartilage leads to inflammation and the formation of osteophytes (bone spurs). Gout does not directly involve chondrocyte injury.

C) An immune complex and autoantibody deposition in connective tissue results in inflammation:

This process describes the pathophysiology of autoimmune diseases such as rheumatoid arthritis, where immune complexes and autoantibodies contribute to inflammation and tissue damage. In gout, the inflammation is primarily triggered by the deposition of urate crystals rather than immune complex deposition.

D) An autoimmune inflammation involving IgG response to an antigen causes joint destruction:

This option describes the autoimmune process seen in diseases like rheumatoid arthritis, where antibodies target specific antigens, leading to joint destruction. Gout is not an autoimmune disease, and joint destruction in gout is primarily due to inflammation caused by urate crystal deposition rather than autoimmune mechanisms.

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Following 2 motor vehicle collision, an adult client is brought to the emergency department with a blood pressure of 72/50 mm Hg and a blood volume loss of approximately 40%. The nurse should plan care for this client based on which expected response to hemorrhaging?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an immobilized client who is at risk for breakdown in skin integrity. Which pathophysiological process should the nurse note early in the development of a pressure injury?

Correct Answer is D

Explanation

A client with a sudden onset of big toe joint pain and swelling is diagnosed with gout. Which pathophysiologic process is producing the symptoms of gout?

Correct Answer is A

Explanation

Which statement is true regarding myocardial functioning in the normal heart, based upon the Frank Starling law?

The nurse is caring for a client who experienced multiple invasive trauma from a motor vehicle collision and has developed systemic inflammatory response syndrome (SIRS). Which pathophysiological process is most likely associated with the development of SIRS in this client?

A client who has asthma (a reactive airway disease) asks the nurse about the role of leukotrienes in this process. Leukotrienes have which immune response?

The nurse is caring for an older client who is on complete bed rest. The nurse notes hematuria when the client suddenly reports excruciating pain that radiates from the back to the groin. Which pathological process has contributed to the client's clinical presentation of a possible renal calculi?

The nurse is caring for a client with intestinal obstruction who presents with severe, colicky abdominal pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation?

The school nurse is teaching a group of clients about how tobacco smoke causes lung cancer. Which pathophysiological process supports the risk of cancer from smoking?