A nurse is assessing a client who sustained multiple injuries in a motor vehicle crash and is at risk for hypovolemic shock. Which assessment findings should the nurse identify as early indicators of the compensatory stage of shock? Select all that apply.
- Restlessness and anxietyAnswer
- Heart rate of 115 beats per minuteAnswer
- CSystolic blood pressure of 72 mm Hg
- Narrowing pulse pressureAnswer
- EWarm, flushed skin
Answer
The early compensatory indicators of hypovolemic shock include restlessness and anxiety, a heart rate of 115 beats per minute, and a narrowing pulse pressure.
In the early, compensatory stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain cardiac output and oxygen delivery to vital organs. This response causes an increase in heart rate (tachycardia) and peripheral vasoconstriction, which leads to a narrowing pulse pressure (because the diastolic pressure rises while the systolic pressure remains stable). Additionally, early cerebral hypoxia and sympathetic stimulation cause neurological changes such as restlessness, apprehension, and anxiety.
Step-by-Step Solution
Key Concept
During the early (compensatory) stage of hypovolemic shock, sympathetic nervous system activation causes tachycardia, a narrowing pulse pressure, and neurological changes like restlessness to maintain blood pressure and vital organ perfusion.