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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Acne vulgaris is a common skin condition characterized by various types of lesions, including comedones, papules, and pustules, primarily affecting areas with a high density of sebaceous glands, such as the face, neck, chest, and upper back. Here's why option C is the correct choice:
A) Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags:
This description is more characteristic of acrochordons or skin tags, which are benign skin growths commonly found in areas of friction or skin folds. Skin tags are not typically associated with acne vulgaris.
B) Hyperpigmented areas that vary in form and color and are slightly elevated from the skin:
This description suggests post-inflammatory hyperpigmentation, which can occur after resolution of inflammatory lesions in acne vulgaris. However, it does not capture the primary pathological findings observed in active acne lesions.
C) Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back:
Correct. Acne vulgaris is characterized by the formation of various lesions, including comedones (open and closed), papules, and pustules, resulting from the obstruction of hair follicles and overactivity of sebaceous glands. These lesions typically appear on areas with a high density of sebaceous glands, such as the face, neck, chest, and upper back.
D) Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees:
This description is more indicative of psoriasis, a chronic autoimmune skin condition characterized by sharply demarcated, raised, silvery scaling plaques commonly affecting extensor surfaces such as the elbows and knees. Psoriasis lesions are distinct from those seen in acne vulgaris.
Correct Answer is A
Explanation
A) Blockage of retinal capillaries causing ischemic damage of the central macular area:
Correct. Blurry central vision that worsens over time can be indicative of macular ischemia, often caused by blockage of retinal capillaries leading to ischemic damage of the central macular area. This condition can occur in diseases such as diabetic retinopathy or retinal vein occlusion.
B) Opaque spoke-like lines developing in the periphery of the lens to the center:
This description is more characteristic of cataracts, which cause visual disturbances such as glare or halos around lights rather than blurry central vision.
C) Tears in the retina that detach from the lining of the posterior eyeball:
Retinal tears and subsequent detachment can cause visual disturbances, but they typically present as sudden onset of floaters, flashes of light, and a curtain-like shadow over the visual field rather than blurry central vision.
D) An increase in intraocular pressure with loss of peripheral vision:
This description is indicative of glaucoma, which can lead to loss of peripheral vision (visual field defects) rather than blurry central vision. Glaucoma-related visual field loss usually begins peripherally and progresses inward, affecting central vision in later stages.
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