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Difficulty: HardPhysiological Adaptation

A nurse is assessing a client who is 4 hours postoperative following a partial hepatectomy. Which of the following assessment findings should the nurse identify as early indicators of developing hypovolemic shock? Select all that apply.

  1. New-onset restlessness and mild agitationAnswer
  2. B
    Arterial blood gas results demonstrating uncompensated respiratory acidosis
  3. A narrowing pulse pressureAnswer
  4. D
    Warm, flushed skin in the distal extremities
  5. Respiratory rate increasing from 14 to 26 breaths per minuteAnswer
  6. F
    A steady decline in resting heart rate

Answer

The correct early indicators of hypovolemic shock are new-onset restlessness and mild agitation, a narrowing pulse pressure, and an increasing respiratory rate.
In the early, compensatory stage of hypovolemic shock, the body's primary goal is to maintain cardiac output and tissue perfusion. The sympathetic nervous system triggers an increase in heart rate and respiratory rate. Peripheral vasoconstriction occurs, which increases the diastolic blood pressure, leading to a narrower pulse pressure. Despite these compensations, subtle decreases in cerebral oxygenation manifest early as behavioral changes, including restlessness, anxiety, or mild agitation.

Step-by-Step Solution

1
Identify the stage and type of shock described in the scenario.
The scenario requires identifying the early (compensatory) stage of hypovolemic shock, typically caused by hemorrhage following major abdominal surgery.
Recognizing the specific stage of shock is critical because assessment findings change drastically as shock progresses from compensatory to progressive, and ultimately to irreversible stages.
2
Analyze physiological responses in the compensatory stage of hypovolemic shock.
The body activates the sympathetic nervous system and the renin-angiotensin-aldosterone system. This leads to tachycardia, tachypnea, peripheral vasoconstriction, and shunting of blood to vital organs.
Understanding the underlying pathophysiology explains the expected vital signs and physical assessment findings.
3
Evaluate each option against the compensatory mechanisms.
Restlessness (decreased cerebral perfusion), narrowing pulse pressure (vasoconstriction raising diastolic pressure), and tachypnea (compensatory oxygen demand) align with early shock. Acidosis, warm skin, and bradycardia do not.
This process eliminates distractors that represent different types of shock (e.g., septic shock) or later stages of physiological decompensation.

Key Concept

Compensatory mechanisms and early clinical manifestations of hypovolemic shock
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Physiological Adaptation

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