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.)

Cool, moist skin.

Increased bowel sounds.

Restlessness.

Increased respiratory rate.

Decreased blood glucose.

Answer and Explanation

Correct Answer : A,C,D

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.

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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. Cyanosis. B. Urticaria. C. Petechiae. D. Ecchymosis.

Correct Answer is B

Explanation

Choice A reason: Cyanosis. Cyanosis, or a bluish tint to the skin, indicates significant hypoxemia or poor oxygenation. While it can occur in severe anaphylaxis, it is not a primary integumentary manifestation.

Choice B reason: Urticaria. Urticaria, or hives, is a common integumentary manifestation of anaphylactic shock. It appears as raised, red, itchy welts on the skin due to an allergic reaction.

Choice C reason: Petechiae. Petechiae are small, pinpoint hemorrhages under the skin and are not typically associated with anaphylactic shock. They are more related to conditions involving bleeding or clotting disorders.

Choice D reason: Ecchymosis. Ecchymosis, or bruising, is not a characteristic manifestation of anaphylactic shock. It is more related to trauma or bleeding disorders.

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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.)

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