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Difficulty: HardPhysiological Adaptation

A nurse is assessing a client who is 4 hours post-admission for a severe pelvic fracture following a motor vehicle crash. The client's baseline vital signs upon admission were: blood pressure 130/76 mm Hg, heart rate 82/min, and respiratory rate 16/min. Which of the following current assessment findings indicate the client is entering the early (compensatory) stage of hypovolemic shock? Select all that apply.

  1. Blood pressure of 116/92 mm HgAnswer
  2. Restlessness and apprehensionAnswer
  3. Respiratory rate of 28/minAnswer
  4. D
    Arterial blood gas revealing a pH of 7.28 and HCO3- of 15 mEq/L
  5. E
    Bounding peripheral pulses
  6. F
    Warm, flushed extremities

Answer

The correct findings indicating early (compensatory) hypovolemic shock are a blood pressure of 116/92 mm Hg, restlessness and apprehension, and a respiratory rate of 28/min.
The compensatory stage of hypovolemic shock is characterized by the body's neural, hormonal, and biochemical mechanisms attempting to maintain perfusion. Sympathetic nervous system activation causes peripheral vasoconstriction, which increases diastolic blood pressure and results in a narrowed pulse pressure (a classic early sign). Decreased cerebral perfusion leads to early changes in level of consciousness, such as restlessness, anxiety, and apprehension. Additionally, the respiratory rate increases (tachypnea) to improve oxygenation and compensate for decreased tissue perfusion.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's risk factors.
The client has a severe pelvic fracture, putting them at high risk for internal hemorrhage and subsequent hypovolemic shock.
Identifying the etiology of potential shock determines what physiological changes to anticipate.
2
Differentiate between the stages of shock (initial, compensatory, progressive, refractory).
The question specifically asks for early (compensatory) signs, which are driven by sympathetic nervous system activation aiming to preserve cardiac output.
Different stages of shock present with distinct clinical manifestations.
3
Evaluate each option against the expected physiological responses in the compensatory stage.
A narrowed pulse pressure, altered mental status (restlessness), and tachypnea align with early compensation. Metabolic acidosis, bounding pulses, and warm extremities align with other shock types or later stages.
Accurate clinical judgment requires distinguishing subtle early signs from overt late signs to initiate timely interventions.

Key Concept

Early recognition of hypovolemic shock requires identifying compensatory mechanisms such as narrowed pulse pressure, tachycardia, tachypnea, and subtle neurological changes rather than waiting for profound hypotension.
Estimated Time:1m 30s
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Physiological Adaptation

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