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Difficulty: MediumPhysiological Adaptation

While assessing a client who is 4 hours postoperative following an exploratory laparotomy, the nurse suspects the onset of hypovolemic shock. Which of the following clinical findings are considered early compensatory manifestations of this condition? Select all that apply.

  1. Narrowed pulse pressureAnswer
  2. Restlessness and apprehensionAnswer
  3. Heart rate of 118 beats/minuteAnswer
  4. D
    Systolic blood pressure of 78 mm Hg
  5. E
    Warm, flushed skin

Answer

The early compensatory manifestations of hypovolemic shock include narrowed pulse pressure, restlessness and apprehension, and tachycardia (e.g., heart rate of 118 beats/minute).
During the early compensatory stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain perfusion. This physiological adaptation causes an increase in heart rate (tachycardia) to boost cardiac output, peripheral vasoconstriction which raises diastolic blood pressure (leading to a narrowed pulse pressure), and mild cerebral hypoxia which manifests clinically as restlessness, apprehension, or anxiety.

Step-by-Step Solution

1
Analyze the client's postoperative status and the physiological risk.
The client is at risk for hypovolemic shock due to potential surgical blood loss or fluid shifts following a laparotomy.
Identifying the etiology of potential shock helps anticipate the expected physiological response.
2
Differentiate between the stages of shock (compensatory versus progressive/decompensated).
The compensatory stage relies on sympathetic nervous system activation to maintain cardiac output and vital organ perfusion.
The question specifically asks for early compensatory manifestations, requiring the exclusion of late findings.
3
Evaluate each assessment finding against the physiological changes of the compensatory stage.
Tachycardia, narrowing pulse pressure, and neurological changes (restlessness) are compensatory. Hypotension is a late sign, and warm skin is atypical for hypovolemic shock.
Accurate identification of early signs allows for prompt, life-saving interventions before irreversible tissue damage occurs.

Key Concept

Early recognition of the compensatory stage of hypovolemic shock
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Topics

Physiological Adaptation

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