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Difficulty: EasyPhysiological Adaptation

A nurse is assessing a client who experienced significant blood loss from a severe laceration. Which assessment findings should the nurse identify as early compensatory signs of hypovolemic shock? Select all that apply.

  1. Heart rate of 112 beats/minuteAnswer
  2. Restlessness and apprehensionAnswer
  3. C
    Urine output of 50 mL/hour
  4. Narrowing pulse pressureAnswer
  5. E
    Warm, flushed skin

Answer

The correct findings include a heart rate of 112 beats/minute, restlessness and apprehension, and a narrowing pulse pressure.
In the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain blood pressure and cardiac output. This results in an increased heart rate (tachycardia) and peripheral vasoconstriction, which causes a narrowing pulse pressure. Additionally, subtle decreases in cerebral perfusion and oxygenation manifest early as restlessness, apprehension, or anxiety.

Step-by-Step Solution

1
Identify the type of shock and its primary cause.
The client has significant blood loss, leading to hypovolemic shock.
Understanding the underlying etiology helps predict the body's compensatory mechanisms.
2
Recall the early compensatory mechanisms for hypovolemia.
The sympathetic nervous system activates, causing tachycardia, peripheral vasoconstriction, and mild cerebral hypoxia.
These physiological changes manifest as specific, recognizable clinical signs.
3
Evaluate each option against known early signs of hypovolemic shock.
Tachycardia, restlessness, and a narrowing pulse pressure align with sympathetic activation and early decreased perfusion.
Differentiating early signs from normal findings or signs of other shock types ensures accurate assessment.

Key Concept

Early compensatory mechanisms in hypovolemic shock include sympathetic nervous system activation, leading to tachycardia, narrowing pulse pressure, peripheral vasoconstriction (cool skin), and altered mental status (restlessness).
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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