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Soru

Zorluk: KolayPhysiological Adaptation

A practical nurse is monitoring a client who is recovering from major abdominal surgery. What data collection findings should the nurse identify as early indicators of hypovolemic shock? (Select all that apply.)

  1. Heart rate of 118 beats/minuteCevap
  2. New-onset restlessness and anxietyCevap
  3. C
    Warm, flushed skin
  4. Urine output of 50 mL over the last 4 hoursCevap
  5. E
    Bounding peripheral pulses

Cevap

The correct early indicators are a heart rate of 118 beats/minute, new-onset restlessness and anxiety, and a urine output of 50 mL over the last 4 hours.
In early hypovolemic shock, the body's compensatory mechanisms immediately activate to maintain cardiac output and vital organ perfusion. The sympathetic nervous system increases the heart rate (tachycardia) to compensate for lower stroke volume. Decreased blood flow to the brain rapidly causes early mental status changes, presenting as restlessness and anxiety. Additionally, the kidneys respond to decreased perfusion by retaining water and sodium, which significantly decreases urine output to preserve intravascular volume.

Adım Adım Çözüm

1
Analyze the client's clinical situation and primary risk factors.
The client recently underwent major abdominal surgery, placing them at high risk for internal bleeding and fluid volume deficit.
Identifying the primary risk helps the nurse anticipate specific physiological complications like hypovolemic shock.
2
Evaluate each assessment finding against the body's expected compensatory mechanisms for fluid loss.
Tachycardia, restlessness, and significant oliguria match the sympathetic nervous system's response to decreased circulating blood volume.
During early shock, the body attempts to compensate by increasing heart rate, shunting blood from non-vital areas, and retaining fluid to maintain blood pressure and perfusion to vital organs.

Anahtar Kavram

Early Signs of Hypovolemic Shock
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Konular

Physiological Adaptation

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