In the plan of care, the most important intervention for a patient experiencing shock is assessing:
Respirations rate.
Heart rate.
Blood pressure.
Temperature.
The Correct Answer is C
A) Respirations rate:
Respiratory rate is an important vital sign to monitor in patients with shock, as respiratory distress can indicate inadequate oxygenation. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.
B) Heart rate:
Heart rate is an important vital sign to monitor in patients with shock, as tachycardia (rapid heart rate) may indicate the body's compensatory response to maintain cardiac output and tissue perfusion. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.
C) Blood pressure.
In shock, the body's vital organs are not receiving adequate blood flow and oxygen, leading to a life-threatening condition. While all vital signs are important to monitor in a patient experiencing shock, blood pressure is typically considered the most critical because it reflects the perfusion pressure—the force driving blood through the circulatory system to deliver oxygen and nutrients to the body's tissues. A decrease in blood pressure can indicate inadequate tissue perfusion and impending organ failure. Therefore, timely assessment and monitoring of blood pressure are essential for identifying and managing shock effectively.
D) Temperature:
Temperature monitoring is important in assessing for signs of infection or other systemic issues that may contribute to shock, such as sepsis. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Cardiogenic shock:
Cardiogenic shock occurs when the heart is unable to pump enough blood to meet the body's needs, often due to myocardial infarction (heart attack) or other conditions affecting the heart's function. The client's history of a recent infection does not align with the etiology of cardiogenic shock.
B) Neurogenic shock:
Neurogenic shock occurs due to dysfunction of the autonomic nervous system, typically as a result of spinal cord injury or severe brain injury. It is characterized by widespread vasodilation and bradycardia. The client's history of a recent infection does not align with the etiology of neurogenic shock.
C) Hypovolemic shock:
Hypovolemic shock occurs due to a significant loss of blood volume, such as from trauma, hemorrhage, or dehydration. While infection can lead to fluid loss and dehydration in some cases, the client's history of a recent infection suggests a different etiology, specifically septic shock, which is driven by the systemic inflammatory response to infection.
D) Septic shock.
Septic shock is a type of distributive shock caused by a systemic response to infection. It occurs when an infection triggers a widespread inflammatory response, leading to vasodilation, increased capillary permeability, fluid loss from the bloodstream, and impaired tissue perfusion. The client's history of a recent infection suggests that the shock may be septic in nature.
Correct Answer is D
Explanation
A) Sedation:
Sedation is not an adverse effect commonly associated with oxymetazoline nasal spray. Oxymetazoline works by constricting blood vessels in the nasal passages to relieve congestion and does not typically cause sedation.
B) Constipation:
Constipation is not an adverse effect associated with oxymetazoline nasal spray. Constipation is more commonly associated with medications that affect the gastrointestinal system, such as opioid analgesics or certain anticholinergic medications.
C) Productive cough:
Productive cough is not an adverse effect commonly associated with oxymetazoline nasal spray. Productive cough refers to a cough that produces mucus or phlegm and is more often associated with respiratory infections or chronic respiratory conditions.
D) Nasal congestion.
Oxymetazoline (Afrin) is a nasal decongestant spray commonly used for the temporary relief of nasal congestion associated with allergic rhinitis or the common cold. However, if oxymetazoline nasal spray is used for more than 3 to 5 consecutive days, it can lead to rebound congestion, also known as rhinitis medicamentosa. Rebound congestion occurs when the nasal mucosa becomes dependent on the medication for vasoconstriction, and upon discontinuation, nasal congestion worsens. Therefore, prolonged use of oxymetazoline nasal spray can result in a worsening of nasal congestion as an adverse effect.
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