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Difficulty: EasyPhysiological Adaptation

A client who recently underwent a large bowel resection is recovering in the surgical unit. The nurse is actively monitoring the client for postoperative complications, specifically fluid volume deficit. Which of the following assessment findings is the earliest indicator that the client is developing hypovolemic shock?

  1. A
    A significant drop in systolic blood pressure below 90 mm Hg
  2. Unexplained restlessness and an increasing resting heart rateAnswer
  3. C
    A sudden decrease in urine output to less than 30 mL per hour
  4. D
    Development of cold, mottled, and clammy skin on the extremities

Answer

Unexplained restlessness and an increasing resting heart rate
In the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion. This physiological adaptation leads to mild tachycardia and causes mild cerebral hypoxia, which presents as unexplained restlessness, apprehension, or anxiety. These are typically the first detectable signs of clinical deterioration, occurring well before blood pressure drops.

Step-by-Step Solution

1
Recall the physiological stages of shock (initial, compensatory, progressive, refractory).
Early shock triggers compensatory mechanisms to maintain cardiac output.
Understanding the timeline of physiological responses is necessary to identify early versus late signs.
2
Identify the effects of the compensatory stage on the body.
The sympathetic nervous system activates, leading to an increased heart rate and subtle changes in mental status due to mild cerebral hypoxia.
These are the body's first attempts to preserve blood flow to vital organs.
3
Differentiate these early signs from late, decompensated signs of shock.
Hypotension, oliguria, and mottled skin occur when compensatory mechanisms begin to fail.
Selecting a late sign would delay critical interventions.

Key Concept

Early Indicators of Hypovolemic Shock
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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