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Zorluk: OrtaReduction of Risk Potential

A nurse is assessing a client admitted with an acute exacerbation of peptic ulcer disease. The client's baseline blood pressure was 134/78134/78 mm Hg, and the resting heart rate was 8282 beats per minute. Which new assessment finding is the most critical early indicator that the client is developing a life-threatening physiological complication?

  1. A blood pressure of 118/92118/92 mm Hg with a resting heart rate of 112112 beats per minute.Cevap
  2. B
    An arterial blood gas (ABG) result showing a pH of 7.447.44, PaCO 2_2 of 3838 mm Hg, and HCO 3−_3^- of 2424 mEq/L.
  3. C
    A single episode of dark, coffee-ground emesis measuring approximately 6060 mL.
  4. D
    A report of sharp, localized epigastric pain that worsens when the client is placed in a flat, supine position.

Cevap

The finding of a blood pressure of 118/92118/92 mm Hg with a resting heart rate of 112112 beats per minute.
In the early (compensatory) stage of hypovolemic shock, which is a major risk for clients with peptic ulcer disease, the sympathetic nervous system is stimulated. This causes peripheral vasoconstriction, which elevates the diastolic blood pressure, leading to a narrowed pulse pressure (the difference between systolic and diastolic pressure). This subtle narrowing, combined with tachycardia, is often the very first detectable sign of hemodynamic compromise, occurring well before a significant drop in systolic blood pressure.

Adım Adım Çözüm

1
Analyze the client's baseline vital signs.
Baseline pulse pressure was 134−78=56134 - 78 = 56 mm Hg. Baseline heart rate was 8282 bpm.
Establishing a baseline is necessary to identify subsequent physiological deterioration.
2
Evaluate the new vital signs for signs of hemodynamic compromise.
New pulse pressure is 118−92=26118 - 92 = 26 mm Hg. The heart rate increased to 112112 bpm.
A narrowing pulse pressure combined with tachycardia is a classic hallmark of the compensatory stage of hypovolemic shock.
3
Compare the severity of the vital sign changes against the other clinical findings.
The ABG is normal, the coffee-ground emesis is expected and small in volume, and the pain worsened by positioning is a typical localized symptom.
The systemic cardiovascular changes represent an immediate, life-threatening risk that takes absolute priority over localized or expected symptoms.

Anahtar Kavram

Early Recognition of Hypovolemic Shock
Tahmini Süre:1m 15s
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Konular

Reduction of Risk Potential

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