A nurse is assessing a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. The nurse suspects the client is developing early compensatory hypovolemic shock due to internal bleeding. Which of the following assessment findings support this clinical judgment? Select all that apply.
- Heart rate steadily increasing from 82 to 112 beats/minute.Cevap
- Pulse pressure narrowing from 45 mm Hg to 28 mm Hg.Cevap
- The client becoming increasingly restless and anxious.Cevap
- DArterial blood gas results indicating uncompensated respiratory acidosis.
- ESystolic blood pressure dropping precipitously to 78 mm Hg.
- FSkin appearing flushed, unusually warm, and dry.
Cevap
The correct findings that indicate early compensatory hypovolemic shock are a steadily increasing heart rate, a narrowing pulse pressure, and increasing restlessness or anxiety.
In the early (compensatory) stage of hypovolemic shock, the body attempts to maintain adequate tissue perfusion and cardiac output. The sympathetic nervous system stimulates an increase in heart rate (tachycardia). Peripheral vasoconstriction increases diastolic blood pressure, leading to a narrowing pulse pressure even while systolic pressure remains relatively stable. Additionally, early slight decreases in cerebral oxygenation manifest as restlessness, apprehension, or anxiety.
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Recognition of the subtle, early compensatory signs of hypovolemic shock, including mild tachycardia, narrowing pulse pressure, and altered mentation, prior to the onset of profound hypotension.