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Difficulty: MediumPhysiological Adaptation

A nurse is assessing a client who underwent a partial hepatectomy 6 hours ago. Which of the following assessment findings should alert the nurse to the development of early (compensatory) hypovolemic shock? Select all that apply.

  1. Narrowing of the pulse pressureAnswer
  2. Heart rate increasing from 84 to 118 beats per minuteAnswer
  3. New-onset restlessness and anxietyAnswer
  4. D
    A sudden drop in systolic blood pressure to 84 mm Hg
  5. E
    Bounding, easily palpable peripheral pulses

Answer

The findings that indicate early hypovolemic shock are a narrowing pulse pressure, an increasing heart rate, and new-onset restlessness and anxiety.
In the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion. This results in an increased heart rate (tachycardia) and vasoconstriction, which raises the diastolic blood pressure and leads to a narrowing pulse pressure. Additionally, subtle decreases in cerebral perfusion trigger early neurological changes such as restlessness, anxiety, and mild confusion.

Step-by-Step Solution

1
Identify the phase of shock being assessed.
The question asks for the early (compensatory) phase of hypovolemic shock.
During the early phase, the body activates compensatory mechanisms to maintain cardiac output and vital organ perfusion despite volume loss.
2
Analyze the physiological compensatory mechanisms associated with early hypovolemia.
Sympathetic nervous system activation causes tachycardia and peripheral vasoconstriction.
These mechanisms attempt to preserve blood flow to the heart and brain.
3
Correlate these mechanisms to the clinical manifestations presented in the options.
Vasoconstriction increases diastolic pressure, leading to a narrowing pulse pressure. Tachycardia manifests as an increased heart rate. Decreased cerebral oxygenation causes early restlessness and anxiety.
These are the direct observable effects of the body's compensatory responses.
4
Differentiate these early signs from late signs or other types of shock.
Hypotension is identified as a late (progressive) sign of shock. Bounding pulses are ruled out, as they occur in early distributive (septic) shock, whereas hypovolemic shock presents with weak, thready pulses.
Accurate clinical judgment requires distinguishing between different stages and etiologies of shock to prevent delayed interventions.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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