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?

Tachycardia.

Lethargic mental status.

Anuria.

Normal blood pressure.

Warm flushed skin.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Tachycardia. In late septic shock, the body attempts to compensate for poor perfusion and low blood pressure by increasing the heart rate. Tachycardia is a common finding as the heart tries to pump more blood to the tissues.

Choice B reason: Lethargic mental status. As septic shock progresses, decreased perfusion to the brain can lead to changes in mental status, such as lethargy or confusion. This reflects the severity of the condition and the impact on the central nervous system.

Choice C reason: Anuria. Anuria, or the absence of urine output, occurs in late septic shock due to severe hypoperfusion and failure of the kidneys. It is a critical sign indicating that the body's organs are shutting down.

Choice D reason: Normal blood pressure. In late septic shock, blood pressure is typically very low due to systemic vasodilation and fluid loss. Normal blood pressure would not be expected at this advanced stage.

Choice E reason: Warm flushed skin. Warm flushed skin is associated with the early stages of septic shock when vasodilation leads to increased blood flow to the skin. In late septic shock, the skin is more likely to be cool and pale due to poor perfusion.

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Correct Answer is C

Explanation

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.

A. Stroke volume x heart rate. B. Afterload x preload. C. Ejection fraction x blood pressure. D. Systolic x diastolic BP.

Correct Answer is A

Explanation

Choice A reason: Stroke volume x heart rate. Cardiac output is the volume of blood the heart pumps per minute, calculated by multiplying the stroke volume (the amount of blood ejected with each heartbeat) by the heart rate (the number of beats per minute).

Choice B reason: Afterload x preload. Afterload and preload are important factors influencing cardiac function but do not directly calculate cardiac output. Afterload refers to the resistance the heart must overcome to eject blood, and preload refers to the initial stretching of the heart muscle prior to contraction.

Choice C reason: Ejection fraction x blood pressure. Ejection fraction is a measure of the percentage of blood ejected from the heart with each beat, and blood pressure is the force exerted by circulating blood on the walls of blood vessels. These factors influence cardiac function but do not directly calculate cardiac output.

Choice D reason: Systolic x diastolic BP. Systolic and diastolic blood pressure are measurements of pressure during heartbeats and between beats, respectively. They are not used to calculate cardiac output.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

Cardiac output (CO) equals:

Correct Answer is A

Explanation

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