The ICU nurse provides care for a 67-year-old female patient experiencing a distributive shock. Assessment findings are indicative of decreasing cardiac output, decreased peripheral perfusion, and increased capillary permeability. The nurse identifies that the patient is in which stage of shock.
Progressive stage
Compensatory stage
Initial stage
Refractory stage
The Correct Answer is A
The stages of shock are commonly described as the initial, compensatory, progressive, and refractory stages. Here is an explanation of each stage and why the patient's assessment findings correspond to the progressive stage:
B. The compensatory stage in (option B) is incorrect because, In the compensatory stage, the body continues to activate compensatory mechanisms to maintain perfusion. This includes increased heart rate, peripheral vasoconstriction, and shunting of blood to vital organs. The patient's assessment findings of decreasing cardiac output, decreased peripheral perfusion, and increased capillary permeability suggest that the body's compensatory mechanisms are no longer sufficient to maintain perfusion adequately. Therefore, the patient has progressed beyond the compensatory stage.
C. The initial stage in (option C) is incorrect because, In the initial stage, there is an initial insult or injury that triggers the shock state. The body's compensatory mechanisms are activated, such as increased heart rate and vasoconstriction, to maintain blood pressure and perfusion. However, the patient's assessment findings indicate that they have progressed beyond the initial stage.
D. The refractory stage in (option D) is incorrect because The refractory stage represents a severe and irreversible state of shock where vital organs fail, and despite interventions, the patient's condition does not improve. The patient's assessment findings do not suggest the refractory stage, as there is still potential for intervention and management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Urine output is an essential indicator of renal perfusion and overall fluid status. In a patient in shock, maintaining an adequate urine output is a crucial goal of fluid resuscitation. A urine output of 0.5 to 1 mL/kg/hour is generally considered adequate in adults. The given value of 35 ml over the last hour suggests that the patient is producing urine, which indicates that fluid resuscitation is effective in restoring perfusion to the kidneys.
A. The patient's mean arterial pressure (MAP) is 50 mm Hg in (option A) is incorrect because While mean arterial pressure is an important hemodynamic parameter, a single value alone may not provide a comprehensive assessment of the patient's response to fluid resuscitation.
B. The patient's GCS score is 9 in (option B) is incorrect because The Glasgow Coma Scale (GCS) assesses the level of consciousness and neurological function but does not directly reflect fluid resuscitation effectiveness.
D. The patient's hemoglobin is within normal limits: (option D) is incorrect because Haemoglobin levels are important for assessing oxygen-carrying capacity but do not directly indicate the effectiveness of fluid resuscitation.
Therefore, the nurse can evaluate that fluid resuscitation for a 70 kg patient in shock is effective by observing a urine output of 35 ml over the last hour.
Correct Answer is A
Explanation
Disseminated intravascular coagulation (DIC) is a condition characterized by both widespread activation of the coagulation system and excessive clotting, leading to the consumption of clotting factors and platelets. This results in a prothrombotic state, which can lead to organ dysfunction and bleeding manifestations.
Elevated D-dimer levels are a characteristic finding in DIC. D-dimer is a fibrin degradation product that is elevated when there is excessive fibrin formation and breakdown. Elevated D-dimer indicates ongoing fibrinolysis and activation of the clotting system.
B. Decreased prothrombin time in (option B) is incorrect because: DIC is characterized by consumption of clotting factors, which can result in prolongation of the prothrombin time (PT) as well as other coagulation tests.
C. Decreased partial thromboplastin time in (option C) is incorrect because Similar to the prothrombin time, the partial thromboplastin time (PTT) can also be prolonged in DIC due to the consumption of clotting factors.
D. Elevated fibrinogen level in (option D) is incorrect because, In DIC, there is consumption of fibrinogen along with other clotting factors. Therefore, elevated fibrinogen levels are not consistent with the pathophysiology of DIC.
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