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Zorluk: KolayPhysiological Adaptation

A nurse is assessing a client who is recovering from a ruptured appendix. The client's temperature is 39.1°C (102.4°F), heart rate is 118 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 100/60 mm Hg. The client's skin feels warm and is visibly flushed. These assessment findings most strongly indicate the early stages of which complication?

  1. Septic shockCevap
  2. B
    Hypovolemic shock
  3. C
    Cardiogenic shock
  4. D
    Neurogenic shock

Cevap

Septic shock
The correct answer is septic shock because the client has a known source of infection (ruptured appendix) and is exhibiting the classic signs of the early, hyperdynamic ('warm') phase of this condition. During this phase, massive systemic vasodilation occurs, resulting in warm, flushed skin, accompanied by a high fever, tachycardia, and tachypnea.

Adım Adım Çözüm

1
Analyze the client's history and vital signs.
The client has a source of infection (ruptured appendix) and presents with fever, tachycardia, tachypnea, and borderline low blood pressure.
Identifying systemic inflammatory responses is crucial for determining the underlying pathology.
2
Evaluate the specific skin assessment findings.
The skin is warm and flushed.
Skin temperature and color help differentiate between the types of shock (e.g., massive vasodilation vs. intense vasoconstriction).
3
Synthesize the findings to identify the complication.
The combination of an infection source, systemic inflammatory signs, and warm, flushed skin from vasodilation points to the hyperdynamic phase of septic shock.
Recognizing this specific triad of symptoms enables prompt, life-saving interventions.

Anahtar Kavram

Early indicators of septic shock (hyperdynamic phase)
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Konular

Physiological Adaptation

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