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Soru

Zorluk: OrtaPhysiological Adaptation

A nurse is monitoring a client admitted with acute pancreatitis who is at risk for hypovolemic shock due to severe fluid shifts. Which assessment finding should the nurse identify as the earliest physiological indicator of this complication?

  1. A narrowing pulse pressure accompanied by mild restlessnessCevap
  2. B
    A decrease in the systolic blood pressure to 85 mm Hg
  3. C
    An arterial blood gas report revealing uncompensated metabolic acidosis
  4. D
    Diminished breath sounds auscultated at the bilateral lung bases

Cevap

A narrowing pulse pressure accompanied by mild restlessness is the earliest indicator of hypovolemic shock.
In the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain blood flow to vital organs. This triggers peripheral vasoconstriction, which elevates the diastolic blood pressure and results in a narrowing pulse pressure. Additionally, mild restlessness is one of the earliest signs of mildly decreased cerebral perfusion.

Adım Adım Çözüm

1
Analyze the clinical scenario and the specific complication.
The client has acute pancreatitis and is at high risk for hypovolemic shock due to third-spacing of fluids. The question requires identifying the earliest sign.
Understanding the timeline of shock progression is critical for timely intervention.
2
Evaluate the physiological response during the initial (compensatory) stage of shock.
The body activates the sympathetic nervous system to maintain cardiac output, causing peripheral vasoconstriction (which narrows the pulse pressure), mild tachycardia, and early neurological changes (restlessness/anxiety) due to slight decreases in cerebral perfusion.
Compensatory mechanisms attempt to mask absolute fluid loss, meaning overt hypotension will not be present initially.
3
Differentiate between early signs and the distractors provided.
Systolic hypotension and metabolic acidosis are progressive, late signs of shock. Diminished breath sounds indicate a localized pulmonary issue, not systemic shock.
Selecting a late sign indicates a failure to recognize the subtle, earlier opportunities for life-saving fluid resuscitation.

Anahtar Kavram

Early vs. Late Indicators of Hypovolemic Shock
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Konular

Physiological Adaptation

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