Examkin

Soru

Zorluk: KolayPhysiological Adaptation

A nurse is monitoring a client who is 4 hours post-operative following abdominal surgery. Which clinical finding should the nurse identify as an early indicator of hypovolemic shock?

  1. Restlessness and an unexplained increase in heart rate.Cevap
  2. B
    A significant decrease in systolic blood pressure below 90 mm Hg.
  3. C
    Cool, mottled skin with sluggish capillary refill.
  4. D
    Incisional pain rated as 7 on a 0 to 10 pain scale.

Cevap

Restlessness and an unexplained increase in heart rate.
In the early (compensatory) stage of hypovolemic shock, the body attempts to maintain cardiac output and oxygen delivery by activating the sympathetic nervous system. This results in an increased heart rate (tachycardia) and early neurological changes, such as restlessness or anxiety, due to subtle decreases in cerebral perfusion.

Adım Adım Çözüm

1
Analyze the client's clinical scenario.
The client is 4 hours post-operative, placing them at high risk for hemorrhage and hypovolemic shock.
Identifying the primary risk factor helps in anticipating possible complications.
2
Recall the physiological stages of shock.
Shock progresses from an early compensatory stage to a progressive, uncompensated stage.
Differentiating between early and late signs of shock is essential to answer the question correctly.
3
Evaluate the options based on early vs. late indicators.
Tachycardia and restlessness are early signs due to sympathetic stimulation. Hypotension and mottling are late signs when compensation fails.
This confirms which finding represents the earliest warning.

Anahtar Kavram

Early indicators of hypovolemic shock include tachycardia, tachypnea, and altered mental status (restlessness) as the body attempts to compensate for decreased fluid volume.
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru