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Difficulty: MediumPhysiological Adaptation

A client is admitted to the emergency department following blunt abdominal trauma from a motor vehicle collision. The nurse is closely monitoring the client for suspected internal hemorrhage. Which of the following assessment findings is the earliest physiological indicator that the client is developing hypovolemic shock?

  1. A
    A decrease in systolic blood pressure below 90 mm Hg
  2. B
    A reduction in urine output to less than 30 mL/hr
  3. Mild tachycardia and a narrowing pulse pressureAnswer
  4. D
    Development of cool, mottled skin on the lower extremities

Answer

Mild tachycardia and a narrowing pulse pressure are the earliest indicators of hypovolemic shock.
In the early (compensatory) stage of hypovolemic shock, the body attempts to maintain cardiac output and vital organ perfusion. The sympathetic nervous system is stimulated, leading to an increased heart rate (mild tachycardia) and peripheral vasoconstriction. This vasoconstriction causes the diastolic blood pressure to rise while the systolic pressure may remain stable or slightly drop, resulting in a narrowing pulse pressure. These are the earliest detectable physiological shifts.

Step-by-Step Solution

1
Identify the client's clinical risk based on the scenario.
The client has blunt abdominal trauma and is at high risk for internal hemorrhage and subsequent hypovolemic shock.
Understanding the clinical risk guides the priority of physical assessments.
2
Recall the physiological progression of hypovolemic shock stages.
Shock progresses from the initial stage to the compensatory stage, followed by progressive and refractory stages.
Recognizing early versus late signs requires understanding how the body attempts to compensate for blood loss.
3
Determine the earliest signs associated with the compensatory stage.
The sympathetic nervous system activates immediately to maintain cardiac output, causing an increased heart rate (tachycardia) and peripheral vasoconstriction, which elevates diastolic blood pressure and narrows the pulse pressure.
These initial hemodynamic changes occur before overt signs like hypotension or altered end-organ perfusion.
4
Evaluate the other options to confirm they represent later stages.
Hypotension, oliguria, and mottled skin all represent progressive or late stages when compensatory mechanisms are failing.
Eliminating late signs confirms the correct early indicator.

Key Concept

Pathophysiology and early recognition of hypovolemic shock
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Topics

Physiological Adaptation

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