A client who has broken his femur presents to the emergency department with the following signs and symptoms: cool, moist skin, increased heart rate, and falling blood pressure. The nurse suspects the client is experiencing:
Low blood glucose
High blood glucose
Hemorrhage
Fluid volume excess
The Correct Answer is C
Choice A reason: Low blood glucose (hypoglycemia) can cause cool, moist skin and tachycardia due to sympathetic activation, but falling blood pressure is less typical unless severe. Femur fractures are associated with significant blood loss, and the symptoms align more closely with hypovolemic shock from hemorrhage than metabolic disturbances like hypoglycemia.
Choice B reason: High blood glucose (hyperglycemia) may cause tachycardia and diaphoresis in severe cases (e.g., diabetic ketoacidosis), but cool, moist skin and falling blood pressure are not primary features. These symptoms are more indicative of hypovolemia from blood loss, as femur fractures can cause significant internal bleeding, making hyperglycemia unlikely.
Choice C reason: Hemorrhage from a femur fracture causes hypovolemic shock, characterized by cool, moist skin (due to vasoconstriction), increased heart rate (compensatory tachycardia), and falling blood pressure (due to volume loss). This is a life-threatening condition requiring urgent fluid resuscitation and hemorrhage control, aligning with the symptoms described and the injury’s severity.
Choice D reason: Fluid volume excess typically presents with edema, hypertension, and bounding pulses, not cool, moist skin or falling blood pressure. A femur fracture is unlikely to cause fluid overload acutely. The symptoms suggest hypovolemia from blood loss, not excess fluid, making this an incorrect diagnosis for the client’s presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Oxygen saturation of 88% in COPD is low but may be baseline for severe disease. It warrants oxygen therapy but is not the most urgent finding. Arterial pH of 7.28 indicates acute respiratory acidosis, a life-threatening complication requiring immediate ventilatory support to correct CO2 retention and acid-base imbalance.
Choice B reason: A respiratory rate of 26 breaths/min indicates tachypnea, common in COPD exacerbation, but is not immediately life-threatening. It reflects respiratory effort to compensate for hypoxia. Arterial pH of 7.28 suggests acute acidosis from CO2 retention, requiring urgent intervention like non-invasive ventilation, making tachypnea a lower priority.
Choice C reason: Accessory muscle use indicates increased work of breathing in COPD exacerbation, signaling distress but not immediate danger. It reflects compensatory efforts for airway obstruction. Arterial pH of 7.28 indicates severe acidosis, a life-threatening condition requiring urgent ventilatory support, making muscle use less critical in this scenario.
Choice D reason: Arterial pH of 7.28 in a COPD exacerbation indicates acute respiratory acidosis due to CO2 retention from hypoventilation. This life-threatening imbalance can lead to coma or cardiac arrest if uncorrected. Immediate intervention, such as non-invasive ventilation, is needed to restore pH and CO2 levels, making this the priority finding.
Correct Answer is B
Explanation
Choice A reason: Blood pressure of 110/70 mm Hg is within normal range and does not indicate hypovolemic shock, which typically presents with hypotension (e.g., <90/60 mm Hg). Early shock may have normal blood pressure, but tachycardia (heart rate 120 beats/min) is a more sensitive indicator of compensatory response to volume loss.
Choice B reason: Heart rate of 120 beats/min indicates tachycardia, a hallmark of hypovolemic shock. In trauma, blood loss reduces circulating volume, triggering sympathetic activation to increase heart rate, compensating for decreased cardiac output. This is the most indicative finding, as it appears early and reflects the body’s response to hypovolemia.
Choice C reason: Warm, dry skin is not typical of hypovolemic shock, which causes cool, clammy skin due to vasoconstriction from sympathetic activation. Warm skin may occur in distributive shock (e.g., sepsis). Tachycardia is a more specific indicator of hypovolemia, making this finding incorrect for the suspected condition.
Choice D reason: Urine output of 40 mL/hr is within normal range (30-50 mL/hr) and does not indicate hypovolemic shock, which typically reduces output (<30 mL/hr) due to decreased renal perfusion. Tachycardia (120 beats/min) is a more immediate and sensitive sign of hypovolemia, making urine output less indicative in early shock.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.