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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Related Questions
Correct Answer is C
Explanation
Hemorrhagic shock is characterized by severe blood loss, leading to inadequate tissue perfusion and hypovolemia. The primary goal in the initial management of hemorrhagic shock is to restore intravascular volume and improve tissue perfusion. Administering intravenous fluids, such as normal saline solution, is a critical intervention to address hypovolemia and improve blood pressure.
A. Give Plasmanate 1 unit now in (option A) is incorrect because: Plasmanate is a plasma-derived product used to replace coagulation factors. While it may be necessary to address coagulation abnormalities, administering intravenous fluids to restore volume takes priority over specific blood products.
B. Prepare for endotracheal intubation in (option B) is incorrect because Endotracheal intubation may be required in cases of impending respiratory failure or compromised airway, but it should not be the first action in addressing hypovolemic shock.
D. Type and crossmatch for 4 units of packed red blood cells (PRBCs) in (option D) is incorrect because transferring packed red blood cells is an important intervention to address blood loss and improve oxygen-carrying capacity. However, before administering blood products, it is crucial to stabilize the patient's hemodynamics through fluid resuscitation.
Therefore, in a patient with hemorrhagic shock, the nurse's first priority among the given options is to give normal saline solution of 250 mL/hr to restore intravascular volume and improve tissue perfusion.
Correct Answer is A
Explanation
Mean arterial pressure (MAP) is a measure of the average pressure within the arteries during one cardiac cycle. It represents the perfusion pressure that drives blood flow to organs and tissues. In the context of shock, a MAP of 50 mm Hg is considered low and indicates inadequate tissue perfusion.
To improve tissue perfusion and restore blood pressure, the nurse would anticipate administering large volumes of intravenous fluids, such as Lactated Ringers (LR). Fluid resuscitation aims to increase intravascular volume and improve cardiac output, ultimately leading to improved tissue perfusion.
B. Cardiac Output (CO) is 4 L/min in (option A) is incorrect because Cardiac output represents the volume of blood pumped by the heart per minute. While a low cardiac output may require intervention, it does not specifically indicate the need for large volumes of fluid administration.
C. Stroke volume is 70 ml/beat in (option C) is incorrect because Stroke volume refers to the volume of blood ejected by the heart with each contraction. While stroke volume can be an important determinant of cardiac output, it alone does not indicate the need for large fluid volumes.
D. The heart rate is 80 bpm in (option D) is incorrect because: Heart rate is the number of heartbeats per minute. While the heart rate can impact cardiac output, it does not provide direct information about fluid resuscitation needs.
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