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Difficulty: HardPhysiological Adaptation

A nurse is monitoring a client who is 3 hours post-operative following a radical nephrectomy. Which of the following assessment findings should the nurse identify as early (compensatory) indicators of hemorrhagic shock? Select all that apply.

  1. Pulse pressure narrowing from 45 mm Hg to 25 mm HgAnswer
  2. Sudden onset of mild restlessness and anxietyAnswer
  3. Apical heart rate increasing from 76 to 112 beats per minuteAnswer
  4. D
    Systolic blood pressure decreasing from 124 mm Hg to 86 mm Hg
  5. E
    Skin on the extremities becoming warm and flushed

Answer

The early compensatory indicators of hemorrhagic shock are a narrowing pulse pressure, a sudden onset of mild restlessness and anxiety, and an increasing apical heart rate.
In the early (compensatory) stage of hemorrhagic shock, the sympathetic nervous system is activated to maintain vital organ perfusion. This causes peripheral vasoconstriction, which raises the diastolic blood pressure, leading to a narrowing pulse pressure. The heart rate increases (tachycardia) to sustain cardiac output. Additionally, mild cerebral hypoxia and sympathetic stimulation manifest early as sudden restlessness, anxiety, or apprehension.

Step-by-Step Solution

1
Analyze the client's clinical context.
The client is 3 hours post-operative for a major abdominal surgery, placing them at high risk for acute internal blood loss and subsequent hypovolemic (hemorrhagic) shock.
Identifying the specific risk profile helps anticipate the physiological signs associated with fluid volume deficit.
2
Recall the pathophysiology of the early (compensatory) stage of shock.
The body activates the sympathetic nervous system to maintain cardiac output and blood pressure. This causes vasoconstriction, tachycardia, and the shunting of blood away from non-vital peripheral tissues toward vital organs.
Understanding the body's compensatory mechanisms is necessary to distinguish early signs from late signs of shock.
3
Evaluate each assessment finding against the expected compensatory responses.
Tachycardia, a narrowing pulse pressure (due to increased diastolic blood pressure from vasoconstriction), and altered mental status (from mild cerebral hypoxia) perfectly match the early stage. Hypotension is a late sign, and warm skin indicates vasodilation, not vasoconstriction.
This elimination process systematically isolates the correct indicators of early hemorrhagic shock.

Key Concept

Early (Compensatory) Signs of Hemorrhagic Shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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