A client with chronic pain is using aspirin regularly to control her pain symptoms. She presents to the hospital with abdominal pain, pale skin, afebrile, and a blood pressure (BP) of 83/45 mm Hg. Which type of shock is the client most likely experiencing?

Hypovolemic shock

Obstructive shock

Cardiogenic shock

Septic shock

Answer and Explanation

The Correct Answer is A

A. Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.
B. Obstructive shock is due to a physical obstruction of blood flow, such as a pulmonary embolism or cardiac tamponade, which does not directly correlate with the client's presentation of symptoms.
C. Cardiogenic shock results from severe heart failure and is typically accompanied by signs of heart dysfunction, not just low blood pressure and abdominal pain.
D. Septic shock is associated with infection and systemic inflammation, often presenting with fever and other signs of infection, which the client is not exhibiting.

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Correct Answer is A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

A. Initiate droplet precautions. B. Prepare to administer antiviral therapy. C. Assess for hemorrhage. D. Assess the respiratory system.

Correct Answer is D

Explanation

A. Droplet precautions are not appropriate for anthrax exposure. Precautions would be based on the specific form of anthrax (cutaneous, inhalation, or gastrointestinal).
B. Anthrax is treated with antibiotics, not antiviral therapy. Ciprofloxacin or doxycycline is typically used for prophylaxis and treatment.
C. While assessing for hemorrhage might be relevant in cases of severe anthrax, it is more critical initially to focus on respiratory assessment, particularly for inhalation anthrax.
D. Assessing the respiratory system is crucial for clients exposed to anthrax, particularly inhalation anthrax, as it can cause severe respiratory symptoms and complications. Prompt assessment is essential for early detection and treatment of respiratory distress.

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A client with chronic pain is using aspirin regularly to control her pain symptoms. She presents to the hospital with abdominal pain, pale skin, afebrile, and a blood pressure (BP) of 83/45 mm Hg. Which type of shock is the client most likely experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations is the priority for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

A nurse is caring for a client who has been exposed to anthrax. Which of the following interventions should the nurse plan to use while caring for this client?

Correct Answer is D

Explanation

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