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Zorluk: KolayPhysiological Adaptation

A nurse is assessing a client who has experienced significant blood loss following a traumatic injury. Which of the following assessment findings should the nurse identify as early indicators of hypovolemic shock? (Select all that apply.)

  1. Heart rate of 118 beats/minCevap
  2. Restlessness and anxietyCevap
  3. C
    Bounding peripheral pulses
  4. D
    Warm, flushed skin

Cevap

The early indicators of hypovolemic shock are a heart rate of 118 beats/min and restlessness and anxiety.
The correct answers identify the compensatory mechanisms that occur during early hypovolemic shock. As blood volume decreases, the sympathetic nervous system is stimulated. This leads to early tachycardia to maintain cardiac output. Additionally, early decreases in cerebral blood flow and oxygenation cause subtle neurological alterations, presenting as restlessness, agitation, or anxiety.

Adım Adım Çözüm

1
Identify the underlying physiological process of early hypovolemic shock.
The body attempts to compensate for decreased circulating blood volume by activating the sympathetic nervous system.
Understanding compensatory mechanisms is essential for predicting early clinical manifestations before profound hypotension occurs.
2
Evaluate each assessment finding against the expected sympathetic nervous system response.
Tachycardia and neurological changes (restlessness) match the compensatory response, while bounding pulses and warm skin do not.
Sympathetic stimulation increases heart rate and causes peripheral vasoconstriction, which shunts blood away from the skin and extremities.

Anahtar Kavram

Early Indicators of Hypovolemic Shock
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Konular

Physiological Adaptation

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