Examkin

Question

Difficulty: HardPhysiological Adaptation

A nurse is evaluating a client who was admitted following a severe pelvic crush injury. Which of the following assessment findings should the nurse identify as indicators that the client is in the early (compensatory) stage of hypovolemic shock? Select all that apply.

  1. A change in blood pressure from 124/76 mm Hg to 112/84 mm HgAnswer
  2. B
    Arterial blood gas results showing pH 7.28, PaCO2 38 mm Hg, and HCO3 16 mEq/L
  3. C
    Mean arterial pressure (MAP) of 56 mm Hg
  4. Unexplained restlessness and mild agitationAnswer
  5. Arterial blood gas results showing pH 7.48, PaCO2 30 mm Hg, and HCO3 22 mEq/LAnswer

Answer

The correct assessment findings are a narrowing pulse pressure (blood pressure changing to 112/84 mm Hg), unexplained restlessness and mild agitation, and an arterial blood gas showing respiratory alkalosis (pH 7.48).
During the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system. This causes peripheral vasoconstriction, which increases diastolic blood pressure and creates a narrowed pulse pressure. Mild cerebral hypoxia presents as restlessness or agitation. Additionally, a compensatory increase in respiratory rate leads to the blowing off of carbon dioxide, resulting in respiratory alkalosis.

Step-by-Step Solution

1
Analyze the physiological changes that occur during the early (compensatory) stage of shock.
The body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion in response to a drop in effective circulating volume.
Understanding the timeline of shock stages is necessary to differentiate early compensatory signs from late progressive signs.
2
Evaluate the hemodynamic and neurological options.
A narrowing pulse pressure (from 48 mm Hg to 28 mm Hg) and mild restlessness indicate early compensatory vasoconstriction and initial cerebral hypoxia. A MAP of 56 mm Hg indicates failure of compensation.
The sympathetic response increases diastolic pressure before systolic pressure falls significantly, while early hypoxia affects the sensitive cerebral cortex first.
3
Evaluate the arterial blood gas (ABG) options.
Tachypnea in early shock causes respiratory alkalosis. Metabolic acidosis occurs later in the progressive stage.
The initial respiratory response to stress and hypoxia blows off CO2, whereas anaerobic metabolism is a later consequence of prolonged hypoperfusion.

Key Concept

Early (Compensatory) Stage of Shock
Rate this question

Topics

Physiological Adaptation

More questions from this topic