What typical sign/symptom indicates the early stage of septic shock?
Tachypnoea and tachycardia
Pallor and cool skin
Blood pressure 84/50 mm Hg
Respiratory acidosis
The Correct Answer is A
In the early stage of septic shock, the body initiates compensatory mechanisms to combat the infection and restore adequate tissue perfusion. Tachypnoea (rapid breathing) and tachycardia (elevated heart rate) are common early signs of septic shock.
Tachypnoea occurs as a response to increased metabolic demand and to compensate for impaired oxygenation and tissue perfusion. Tachycardia is the body's attempt to maintain cardiac output and compensate for decreased blood pressure.
B. Pallor and cool skin in (option B) is incorrect because Pallor and cool skin can occur in later stages of septic shock when perfusion to the peripheral tissues is compromised. However, they are not specific to the early stage.
C. Blood pressure 84/50 mm Hg in (option C) is incorrect because A blood pressure reading of 84/50 mm Hg indicates hypotension, which is typically seen in later stages of septic shock. In the early stage, blood pressure may still be within normal or slightly decreased range.
D. Respiratory acidosis in (optionD) is incorrect because: Respiratory acidosis refers to an imbalance in acid-base status and is not specific to the early stage of septic shock. Acid-base disturbances may occur at any stage of shock but are not indicative of the early stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Auscultate for the presence of bilateral breath sounds.
It's an important check, but it is not the most reliable initial method because breath sounds can sometimes be misleading (for example, sounds may be heard in the stomach or transmitted incorrectly).
B. Use an end-tidal CO₂ monitor to check for placement in the trachea.
It's the correct answer. Continuous waveform capnography or end-tidal CO₂ detection is the most reliable and immediate method to confirm that the endotracheal tube is in the trachea and not in the esophagus. Presence of CO₂ indicates effective airway placement.
C. Observe the chest for symmetrical movement with ventilation.
Chest rise is helpful, but it is not specificboth esophageal and tracheal intubation may show chest movement.
D. Obtain a portable chest radiograph to check tube placement.
It's the gold standard for final confirmation, but it is not the initial bedside method because it takes time.
Correct Answer is ["A","B","C"]
Explanation
These conditions can lead to fluid loss, either through increased gastrointestinal output (diarrhea, vomiting, lower GI bleeding) or accumulation of air in the pleural space (tension pneumothorax), resulting in a decrease in blood volume and subsequent hypovolemic shock.
E. Diabetes insipidus in (option E) is incorrect because it is not directly associated with hypovolemic shock. Diabetes insipidus is a condition characterized by excessive thirst and the production of large volumes of dilute urine due to insufficient production or response to antidiuretic hormone (ADH). While diabetes insipidus can lead to dehydration and potential hypovolemia, it is not a direct cause of hypovolemic shock.
F. Valvular stenosis in (option F) is incorrect because it is a condition characterized by the narrowing or obstruction of one or more heart valves. While it can cause problems with cardiac output and circulation, it is not specifically related to hypovolemic shock, which is caused by a decrease in blood volume.
Therefore, the conditions that can cause hypovolemic shock include diarrhea, vomiting, lower GI bleeding, and tension pneumothorax.
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