The nurse is caring for a patient who is experiencing shock. What finding would the nurse expect when assessing the abdomen?

Hyperactive bowel sounds

Diffuse tenderness upon palpation

Hypoactive bowel sounds

Evidence of Cullen's sign

Answer and Explanation

The Correct Answer is C

Choice A reason:

Hyperactive bowel sounds are not typically associated with shock. Shock, particularly in its later stages, often leads to reduced perfusion to the gastrointestinal tract, which can cause decreased bowel activity. Hyperactive bowel sounds might be seen in other conditions such as gastrointestinal infections or bowel obstructions but are not characteristic of shock.

Choice B reason:

Diffuse tenderness upon palpation can be seen in various abdominal conditions, such as peritonitis or appendicitis, but it is not a hallmark sign of shock. While abdominal tenderness can occur if the patient has experienced trauma to the abdomen, it is not a primary sign used to diagnose shock.

Choice C reason:

Hypoactive bowel sounds are a common finding in patients experiencing shock. As the body prioritizes blood flow to vital organs like the brain and heart, blood flow to the gastrointestinal tract is reduced, leading to decreased bowel activity. This is consistent with the body's physiological response to shock and makes hypoactive bowel sounds the correct choice.

Choice D reason:

Cullen's sign, which is bruising around the umbilicus, is indicative of intra-abdominal bleeding, such as from pancreatitis or ruptured ectopic pregnancy. It is not a general sign of shock and would not be expected in all shock patients. Therefore, Cullen's sign is not the correct answer in this context.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Cool, moist skin. Cool, moist skin is an early sign of shock as the body redirects blood flow away from the skin to vital organs. This is part of the body's compensatory mechanisms to maintain perfusion.

Choice B reason: Increased bowel sounds. Bowel sounds typically decrease during shock due to reduced blood flow to the gastrointestinal tract. Increased bowel sounds would not be expected.

Choice C reason: Restlessness. Restlessness is an early sign of shock indicating reduced oxygen delivery to the brain. The body responds by becoming more alert and anxious, reflecting increased sympathetic nervous system activity.

Choice D reason: Increased respiratory rate. An increased respiratory rate is a compensatory mechanism to improve oxygenation and reduce carbon dioxide levels in the blood. This is common in the early stages of shock.

Choice E reason: Decreased blood glucose. Blood glucose levels are generally not an immediate indicator in the early stages of shock. The body's stress response can actually increase blood glucose levels initially.

A. Hypotension, rapid thready pulse, cool pale skin. B. Increased urine output. C. Pale, mottled, or cyanotic skin. D. Stupor and loss of reflexes.

Correct Answer is A

Explanation

Choice A reason: Hypotension, rapid thready pulse, cool pale skin. In the compensatory stage of shock, the body attempts to maintain blood pressure and perfusion by increasing the heart rate and constricting blood vessels. Despite these efforts, hypotension can occur, and the skin may become cool and pale due to reduced blood flow to the periphery.

Choice B reason: Increased urine output. In shock, particularly during the compensatory stage, urine output typically decreases as the body attempts to conserve fluids. Increased urine output would not be expected in this context.

Choice C reason: Pale, mottled, or cyanotic skin. These skin changes are more characteristic of the progressive or irreversible stages of shock, indicating severe hypoperfusion and tissue hypoxia. In the compensatory stage, the skin is usually cool and pale, but not yet mottled or cyanotic.

Choice D reason: Stupor and loss of reflexes. These neurological changes are more typical of the later stages of shock when perfusion to the brain is severely compromised. In the compensatory stage, mental status changes may be present but are less severe.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient who is experiencing shock. What finding would the nurse expect when assessing the abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings indicate to the nurse that a client is exhibiting early clinical manifestations of the compensatory stage of shock? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The compensatory stage of shock results in what assessment findings?

Correct Answer is A

Explanation

What is the initial therapy of choice for the treatment of anaphylactic shock?

What clinical manifestation distinguishes or separates neurogenic shock from other forms of shock?

The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8°F oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?

The nurse working in the ICU is receiving a client diagnosed with late septic shock. The nurse correlates which clinical manifestations to this stage of septic shock?

The nurse caring for a client in the early stages of hypovolemic shock who is hyperventilating. The nurse monitors for which acid-base imbalance based on this clinical presentation?

The pathophysiology of shock is best described as:

What is an integumentary manifestation of anaphylactic shock?

Cardiogenic shock occurs when the heart's pumping ability is compromised. What can impair the pumping ability of the heart? Select all that apply.