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Zorluk: KolayPhysiological Adaptation

A nurse is caring for a client who has experienced profuse, watery diarrhea for the past 48 hours. The nurse monitors the client closely for early indications of hypovolemic shock. Which of the following vital sign changes represents the earliest physiological compensatory mechanism for fluid volume deficit?

  1. An increase in resting heart rateCevap
  2. B
    A sudden decrease in systolic blood pressure
  3. C
    A widening of the pulse pressure
  4. D
    A decrease in the respiratory rate

Cevap

An increase in resting heart rate
The body's initial compensatory response to fluid volume depletion is activation of the sympathetic nervous system, which causes an increased heart rate (tachycardia) to maintain cardiac output and tissue perfusion. This typically occurs before any significant drop in blood pressure can be observed.

Adım Adım Çözüm

1
Identify the primary clinical risk based on the client's history.
The client's severe diarrhea leads to significant fluid volume deficit, increasing the risk for hypovolemic shock.
Recognizing the underlying fluid loss is the first step in anticipating the body's physiological responses.
2
Recall the body's initial compensatory mechanisms for decreased intravascular volume.
The sympathetic nervous system activates immediately to maintain cardiac output and tissue perfusion, primarily by increasing the heart rate.
Tachycardia occurs as an early warning sign, compensating for the lower stroke volume before the blood pressure drops.
3
Evaluate the other vital sign options against the known progression of shock.
Hypotension is a late sign. Respiratory rate generally increases. Pulse pressure narrows due to vasoconstriction.
Distinguishing between early compensatory signs and late decompensatory signs is critical for prompt nursing intervention.

Anahtar Kavram

Early compensatory mechanisms in hypovolemic shock
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Konular

Physiological Adaptation

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