Examkin

Question

Difficulty: MediumPhysiological Adaptation

A surgical nurse is evaluating a client who is 4 hours post-operative following a total abdominal hysterectomy. Which of the following assessment findings are early clinical indicators of developing hypovolemic shock? Select all that apply.

  1. Heart rate increase from 75 to 118 beats per minuteAnswer
  2. B
    Gradual widening of the pulse pressure
  3. Sudden onset of unexplained restlessness and apprehensionAnswer
  4. D
    Warm, flushed skin on the distal extremities
  5. Respiratory rate increase from 14 to 24 breaths per minuteAnswer

Answer

The correct findings that indicate early hypovolemic shock are an increased heart rate, the sudden onset of restlessness and apprehension, and an increased respiratory rate.
The correct selections represent the body's early compensatory mechanisms for volume loss. Sympathetic nervous system activation causes tachycardia and tachypnea to maintain oxygen delivery, while decreased cerebral perfusion manifests early as restlessness and apprehension.

Step-by-Step Solution

1
Analyze the pathophysiology of early hypovolemic shock.
Recognize that the initial physiological response involves sympathetic nervous system activation.
Compensatory mechanisms attempt to immediately maintain cardiac output and tissue perfusion.
2
Evaluate each assessment finding against early compensatory signs.
Identify tachycardia, tachypnea, and neurological changes (restlessness) as early signs.
These specific signs reflect the body's immediate attempt to oxygenate and supply vital organs like the brain.
3
Differentiate early signs from late signs or other types of shock.
Eliminate widening pulse pressure and warm, flushed skin from the correct selections.
Hypovolemic shock causes a narrowed pulse pressure and cool, clammy skin due to peripheral vasoconstriction.

Key Concept

Early Indicators of Hypovolemic Shock
Rate this question

Topics

Physiological Adaptation

More questions from this topic