The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:

initial stage of septic shock.

refractory stage of obstructive shock.

progressive stage of hypovolemic shock.

compensatory stage of diabetic shock.

Answer and Explanation

The Correct Answer is C

A. Initial stage of septic shock

Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.

B. Refractory stage of obstructive shock

Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.

C. Progressive stage of hypovolemic shock

The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).

D. Compensatory stage of diabetic shock

"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.

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Correct Answer is B

Explanation

A. Control dysrhythmias and decrease the heart rate

Controlling dysrhythmias is important, but decreasing heart rate is not always the goal, as a compensatory tachycardia may be necessary for perfusion.

B. Decrease cardiac workload and increase systemic perfusion

Cardiogenic shock results from impaired cardiac output. The goal is to reduce the heart’s workload (e.g., by reducing afterload) while improving systemic perfusion.

C. Improve oxygen exchange and decrease urinary output

Oxygenation is important, but decreased urinary output indicates poor renal perfusion and worsening shock, which is not a goal of treatment.

D. Decrease the blood pressure and respiratory rate

In cardiogenic shock, blood pressure is already low. The goal is to maintain adequate perfusion, not to further reduce BP.

A. Removal of the educating patient to carry an Epipen B. Assess and document for previous allergies and drug reactions prior to medication administration C. Administer diphenhydramine and solumedrol IV and solumedrol IV at the first sign of allergic symptoms D. Application of red allergy bracelet patient's upper extremity

Correct Answer is B

Explanation

A. Removal of the educating patient to carry an Epipen
While educating the patient about carrying an Epipen is essential in managing anaphylaxis, it is not the primary action in preventing anaphylactic shock before exposure to an allergen.

B. Assess and document for previous allergies and drug reactions prior to medication administration
Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.

C. Administer diphenhydramine and solumedrol IV at the first sign of allergic symptoms
These medications help in managing allergic reactions but do not prevent anaphylactic shock. Preventive measures focus on avoiding allergen exposure rather than treating symptoms after they occur.

D. Application of a red allergy bracelet on the patient’s upper extremity
This helps alert healthcare providers about allergies, but it does not prevent anaphylactic shock. It is a precautionary step rather than a primary prevention strategy.

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Naxlex Comprehensive Predictor Exams

What is the goal of treatment for the client diagnosed with cardiogenic shock?

Correct Answer is B

Explanation

What action priority in preventing anaphylactic shock?

Correct Answer is B

Explanation

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