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Difficulty: MediumPhysiological Adaptation

A nurse is assessing a client who has experienced severe vomiting and diarrhea for the past 3 days. Which assessment findings indicate the client has developed early compensatory hypovolemic shock? Select all that apply.

  1. Narrowing of the pulse pressure to 28 mm HgAnswer
  2. New onset of restlessness and apprehensionAnswer
  3. Respiratory rate increasing to 28 breaths per minuteAnswer
  4. D
    Systolic blood pressure of 78 mm Hg and profound lethargy
  5. E
    Arterial blood gas revealing a pH of 7.25 and PaCO2 of 55 mm Hg

Answer

The correct findings that indicate early compensatory shock are the narrowing of the pulse pressure, new onset of restlessness and apprehension, and an increased respiratory rate.
The compensatory phase of shock is an early stage where the body attempts to maintain cardiac output and tissue perfusion despite volume loss. The sympathetic nervous system stimulates peripheral vasoconstriction, which causes a narrowing pulse pressure (a smaller difference between systolic and diastolic blood pressure). It also triggers tachypnea (an increased respiratory rate) to improve oxygenation, which typically results in a mild respiratory alkalosis. Additionally, slight cerebral hypoxia and sympathetic stimulation cause early neurological changes such as restlessness, anxiety, and apprehension.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a history of severe fluid loss (vomiting and diarrhea), placing them at high risk for hypovolemic shock.
Identifying the risk factors helps anticipate expected physiological changes.
2
Recall the physiological changes during the compensatory phase of shock.
The body activates the sympathetic nervous system, leading to vasoconstriction, increased heart rate, and increased respiratory rate to maintain systemic perfusion.
Understanding the pathophysiology of compensatory shock is required to accurately identify its early signs.
3
Evaluate each option against the signs of early compensatory shock.
Narrowing pulse pressure, restlessness, and tachypnea are early signs. Severe hypotension and lethargy are late signs. Respiratory acidosis is incorrect as early shock causes respiratory alkalosis.
Differentiating between early and late signs of shock ensures accurate assessment and prevents misinterpretation of diagnostic values.

Key Concept

Early compensatory mechanisms of hypovolemic shock
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Topics

Physiological Adaptation

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