A client is being admitted to the emergency department with a possible dissecting abdominal aortic aneurysm. Which of the following clinical manifestations are not signs and symptoms of hypovolemic shock?
Nausea and faintness
Neurologic deficits and apprehension
Hypertension and tachypnea
Diaphoresis and oliguria
The Correct Answer is C
Choice A reason: Nausea and faintness Nausea and faintness can be symptoms of hypovolemic shock. Hypovolemic shock occurs when the body loses a significant amount of blood or fluids, leading to a decrease in blood pressure and inadequate oxygen supply to the organs. This can cause various symptoms, including nausea and faintness, as the body struggles to maintain normal function.
Choice B reason: Neurologic deficits and apprehension Neurologic deficits and apprehension can also be symptoms of hypovolemic shock. Neurologic deficits refer to abnormal neurologic function of a body area due to injury of the brain, spinal cord, muscles, or nerves. Apprehension, or anxiety, can occur as the body responds to the stress of significant blood or fluid loss.
Choice C reason: Hypertension and tachypnea Hypertension, or high blood pressure, is not typically a symptom of hypovolemic shock. In fact, hypovolemic shock is usually characterized by hypotension, or low blood pressure, due to the loss of blood or fluids. Tachypnea, or rapid breathing, can be a symptom of hypovolemic shock, but it would not typically be accompanied by hypertension in this context.
Choice D reason: Diaphoresis and oliguria Diaphoresis (excessive sweating) and oliguria (reduced urine production) can be symptoms of hypovolemic shock. Diaphoresis can occur as the body attempts to cool itself in response to the stress of significant blood or fluid loss. Oliguria can occur as the kidneys receive less blood flow due to the decrease in blood volume, leading to decreased urine production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Providing oral care every 4 hours and as needed is an evidence-based practice to lower the risk of ventilator-associated pneumonia by minimizing the buildup of bacteria in the mouth³.
Choice B reason:Positioning the head of the client's bed in the flat position is not recommended as it can increase the risk of aspiration; elevating the head of the bed to 30° to 45° is the standard practice.
Choice C reason:Turning the client every 4 hours is important for preventing pressure ulcers and improving lung function but is not the primary action for reducing pneumonia risk³.
Choice D reason:Providing humidity helps to maintain mucous membrane integrity but must be carefully managed to prevent bacterial growth and is not the primary action for reducing pneumonia risk³.
Correct Answer is C
Explanation
Choice A reason: Metabolic alkalosis would present with an elevated pH and HCO3, which is not the case here.
Choice B reason: Respiratory alkalosis would present with an elevated pH and a decreased PaCO2, which is not the case here.
Choice C reason: Metabolic acidosis is indicated by a decreased pH and HCO3, which aligns with the ABG findings provided.
Choice D reason: Respiratory acidosis would present with a decreased pH and an elevated PaCO2, which is not the case here.
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