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

Restlessness

Cool moist skin

Increased bowel sounds

Increased respiratory rate

Decreased blood glucose

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Restlessness is one of the early clinical manifestations of the compensatory stage of shock. The body responds to decreased tissue perfusion and oxygenation by stimulating the sympathetic nervous system, which results in anxiety and restlessness. This response indicates that the body's compensatory mechanisms are being activated in an attempt to maintain adequate blood flow and oxygenation to vital organs. The increased release of catecholamines leads to these symptoms as the body tries to compensate for the shock state.

Choice B reason: Cool moist skin is another early sign of the compensatory stage of shock. During this stage, peripheral vasoconstriction occurs as the body attempts to redirect blood flow to vital organs like the heart and brain. This vasoconstriction leads to reduced blood flow to the skin, causing it to become cool and clammy. The skin's moisture is due to the activation of sweat glands, another effect of the sympathetic nervous system's response to shock. This mechanism is essential for preserving core body temperature and ensuring that critical organs receive adequate perfusion during the shock state.

Choice C reason: Increased bowel sounds are not typically associated with the compensatory stage of shock. Instead, the body’s response to shock generally includes decreased gastrointestinal activity due to the redirection of blood flow away from the gastrointestinal tract. This prioritization of blood flow to vital organs like the heart, lungs, and brain leads to a reduction in digestive functions. Therefore, increased bowel sounds are unlikely to be an early manifestation of the compensatory stage of shock, making this choice incorrect in the context of shock assessment.

Choice D reason: Increased respiratory rate is a key indicator of the compensatory stage of shock. As the body attempts to compensate for reduced oxygen delivery to tissues, the respiratory rate increases to enhance oxygen uptake and carbon dioxide elimination. This tachypnea helps to maximize oxygenation and support metabolic needs during the early stages of shock. The body's drive to maintain homeostasis triggers this response, ensuring that despite the decreased perfusion, oxygen levels in the blood are maintained as much as possible.

Choice E reason: Decreased blood glucose is not typically an early sign of the compensatory stage of shock. In fact, the body's stress response to shock usually involves the release of stress hormones like cortisol and catecholamines, which can increase blood glucose levels by stimulating gluconeogenesis and glycogenolysis. This increase in blood glucose provides additional energy to vital organs during the stressful period. Hence, decreased blood glucose is not considered a primary early manifestation of the compensatory stage of shock.

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Correct Answer is B

Explanation

Choice A reason:

Septic shock is caused by severe infections leading to systemic inflammation and vasodilation. Symptoms often include fever, increased heart rate, low blood pressure, and signs of infection. While the vital signs in this scenario include tachycardia and hypotension, there is no indication of infection, fever, or other signs that would suggest sepsis as the primary cause of the shock.

Choice B reason:

Hypovolemic shock results from a significant loss of blood or fluids, common in traumatic injuries. The patient's tachycardia, hypotension, and decreased pulse oximetry indicate a possible significant blood loss due to the trauma from the motor vehicle accident. These signs are typical for hypovolemic shock, making it the most likely diagnosis given the context.

Choice C reason:

Cardiogenic shock is caused by the heart's failure to pump effectively, often due to myocardial infarction or heart disease. While hypotension and tachycardia are present, there are no other indicators, such as chest pain or history of heart disease, to suggest that the patient's shock is cardiogenic in nature. The context of a traumatic accident points more towards hypovolemic shock.

Choice D reason:

Anaphylactic shock is a severe allergic reaction causing widespread vasodilation and bronchoconstriction. Symptoms include sudden hypotension, tachycardia, and difficulty breathing. There is no mention of an allergen exposure or typical allergic reactions (such as rash, itching, or swelling) in the patient's history, making anaphylactic shock an unlikely cause of the symptoms described.

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.

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

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

The compensatory stage of shock results in what assessment findings?

Correct Answer is A

Explanation

The nurse understands that which hemodynamic parameters are consistent with hypovolemic shock? Decreased cardiac output and:

During the initial stage of shock, which manifestation should the nurse monitor for when assessing the client?

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

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

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

What is a late sign of septic shock?

Cardiac output (CO) equals:

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