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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This pathway represents the normal sequence of electrical impulses that coordinate the contraction and relaxation of the heart chambers.
The electrical signal originates from the sinoatrial (SA) node, which is often referred to as the natural pacemaker of the heart. It is located in the right atrium and generates the electrical impulses that initiate each heartbeat. From the SA node, the electrical signal travels to the atrioventricular (AV) node, which is located at the junction between the atria and ventricles.
After passing through the AV node, the electrical impulse travels through the bundle of His (also known as the atrioventricular bundle) and divides into the right and left bundle branches. These branches continue the conduction pathway and deliver the electrical signal to the Purkinje fibers.
The Purkinje fibers spread the electrical impulse rapidly throughout the ventricles, stimulating the contraction of the ventricular muscle and allowing for efficient pumping of blood out of the heart.
Therefore, the correct sequence of the normal conduction pathway in the heart is:
A. SA node - AV node - bundle of His - bundle branches - Purkinje fibers.
Correct Answer is B
Explanation
Fresh frozen plasma (FFP) is a blood product that contains various clotting factors, including factors II, V, VII, VIII, IX, X, XI, and XIII. These clotting factors are essential for the normal coagulation process. In patients with shock, coagulation abnormalities can occur, and administration of FFP can help replenish the deficient clotting factors and restore proper coagulation function.
The other options mentioned are not the primary components replaced by fresh frozen plasma:
A. Red blood cells are in (option A) is incorrect because Red blood cells carry oxygen and are typically replaced by packed red blood cell transfusions in cases of significant blood loss or anemia. Fresh frozen plasma does not contain a significant amount of red blood cells.
C. Platelets in (option C) is incorrect because: Platelets play a role in blood clotting and are typically replaced by platelet transfusions in cases of thrombocytopenia or platelet dysfunction. Fresh frozen plasma may contain a small number of platelets but is not the primary source for platelet replacement.
D. White blood cells in (option D) is incorrect because White blood cells are part of the immune system and are not typically replaced using fresh frozen plasma. Fresh frozen plasma does not contain a significant amount of white blood cells.
Therefore, fresh frozen plasma is primarily administered to patients in shock to replace clotting factors and help restore proper coagulation function.
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