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Difficulty: EasyPhysiological Adaptation

A nurse is assessing a client who is postoperative and at risk for hemorrhage. Which of the following clinical findings indicate the client is developing early hypovolemic shock? Select all that apply.

  1. Heart rate of 118 beats per minuteAnswer
  2. Restlessness and anxietyAnswer
  3. C
    Warm, flushed skin
  4. D
    Increased urine output

Answer

The early signs of hypovolemic shock include a heart rate of 118 beats per minute and restlessness and anxiety.
In the early (compensatory) stage of hypovolemic shock, the body's sympathetic nervous system activates to maintain perfusion. This leads to an increased heart rate (tachycardia) to boost cardiac output. Additionally, early cerebral hypoxia and adrenaline release frequently manifest as restlessness, agitation, or anxiety.

Step-by-Step Solution

1
Analyze the client's condition and risk factors.
The client is postoperative and at risk for hemorrhage, which can rapidly lead to hypovolemic shock.
Identifying the primary clinical risk helps anticipate the body's physiological compensatory mechanisms.
2
Identify the body's early physiological adaptation to fluid loss.
The sympathetic nervous system activates, causing tachycardia, peripheral vasoconstriction, and fluid retention.
Compensatory mechanisms attempt to maintain cardiac output and tissue perfusion.
3
Evaluate each option against early shock manifestations.
Tachycardia and restlessness are early signs. Warm skin and increased urine output are incorrect.
Blood is shunted from the skin (causing it to be cool) and kidneys (decreasing urine output) to protect vital internal organs.

Key Concept

Early Manifestations of Hypovolemic Shock
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Topics

Physiological Adaptation

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