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Question

Difficulty: EasyPhysiological Adaptation

A nurse is monitoring a postoperative client for signs of hemorrhage. Which of the following assessment findings is the earliest physiological indicator that the client is developing hypovolemic shock?

  1. Mild tachycardia and restlessnessAnswer
  2. B
    Profound hypotension and lethargy
  3. C
    Bradycardia and a widened pulse pressure
  4. D
    Cyanosis and absent peripheral pulses

Answer

Mild tachycardia and restlessness are the earliest indicators of hypovolemic shock.
In the early, compensatory stage of hypovolemic shock, the sympathetic nervous system is stimulated in response to decreased blood volume. This results in an increased heart rate (mild tachycardia) to maintain cardiac output, and decreased oxygen delivery to the cerebral cortex often manifests early as restlessness, mild anxiety, or confusion. Blood pressure typically remains normal during this initial phase.

Step-by-Step Solution

1
Identify the primary condition being assessed
The nurse is looking for early signs of hypovolemic shock due to potential postoperative hemorrhage.
Understanding the timeline of shock (early vs. late) is crucial for accurate assessment.
2
Evaluate physiological compensatory mechanisms
In early shock, the sympathetic nervous system activates, causing an increased heart rate to maintain cardiac output, and slight hypoxia to the brain causes altered mental status like restlessness.
The body compensates before blood pressure drops.
3
Differentiate early from late signs
Hypotension, lethargy, and cyanosis only occur after compensatory mechanisms fail.
Waiting for a drop in blood pressure delays critical life-saving interventions.

Key Concept

Early indicators of hypovolemic shock include subtle vital sign changes (mild tachycardia) and altered mental status (restlessness) prior to a drop in blood pressure.
Estimated Time:45s
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Topics

Physiological Adaptation

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