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Difficulty: HardPhysiological Adaptation

A practical nurse (PN) is collecting data on a 68-year-old client admitted with a severe upper gastrointestinal bleed. Which of the following assessment findings indicate the client is developing hypovolemic shock and require immediate escalation to the registered nurse? Select all that apply.

  1. The client becomes acutely restless and repeatedly asks where they are.Answer
  2. Radial pulses are weak and thready with a rate of 124 beats/min.Answer
  3. Urine output is 15 mL over the past hour.Answer
  4. D
    The client reports mild nausea and abdominal cramping.
  5. E
    Capillary refill time is 2 seconds in the bilateral upper extremities.
  6. F
    The client's spouse notes a known history of mild dementia.

Answer

The findings that require immediate escalation are acute restlessness and confusion, weak and thready tachycardia, and oliguria (urine output of 15 mL/hr).
The correct findings represent acute physiological adaptation failure due to severe intravascular volume loss. Restlessness and confusion are early signs of cerebral hypoxia. A heart rate of 124 beats/min with weak pulses indicates a compensatory sympathetic response to drastically decreased stroke volume. A urine output of 15 mL/hr (oliguria) demonstrates decreased renal perfusion as the body aggressively shunts blood to preserve core organs. All of these signify impending cardiovascular collapse and require immediate emergency intervention.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's risk factors.
The client has an active upper gastrointestinal bleed, placing them at extremely high risk for significant fluid volume loss and impending hypovolemic shock.
Identifying the primary risk factor guides the focus of data collection toward evaluating hemodynamic stability and tissue perfusion.
2
Evaluate each assessment finding against the clinical manifestations of hypovolemic shock.
Restlessness/confusion (cerebral hypoxia), weak tachycardia (compensatory mechanism), and decreased urine output (renal shunting) are identified as critical indicators of physiological deterioration.
These specific signs demonstrate that the body is failing to adapt to the volume loss and requires immediate emergency intervention to prevent cardiovascular collapse.
3
Eliminate expected, normal, or non-emergent chronic findings.
Mild nausea, normal capillary refill time, and chronic dementia are eliminated as they do not represent acute, life-threatening changes.
Safe nursing practice requires prioritizing acute airway, breathing, and circulation (ABC) issues over expected symptoms or stable chronic conditions.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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