A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
Blood pressure of 84/50 mm Hg
Confusion
Anuria
Petechiae
The Correct Answer is B
Choice A reason: Blood pressure of 84/50 mm Hg indicates decompensated shock, not the compensatory stage. In the compensatory stage, the body maintains blood pressure through vasoconstriction and tachycardia. Hypotension suggests failure of compensatory mechanisms, leading to inadequate tissue perfusion and progression to a more severe stage of shock, requiring immediate intervention.
Choice B reason: Confusion is a hallmark of the compensatory stage of shock. Reduced cerebral perfusion due to decreased blood volume or cardiac output impairs brain function, causing altered mental status. The sympathetic nervous system is activated, redirecting blood to vital organs, but subtle neurological changes like confusion occur as early signs of inadequate oxygen delivery to the brain.
Choice C reason: Anuria, or absence of urine output, is characteristic of the progressive or decompensated stage of shock. In the compensatory stage, urine output is reduced (oliguria) as the kidneys conserve fluid via the renin-angiotensin-aldosterone system. Anuria indicates severe renal hypoperfusion, which occurs later when compensatory mechanisms fail to maintain adequate circulation.
Choice D reason: Petechiae, small hemorrhagic spots on the skin, are not typical in the compensatory stage of shock. They may occur in disseminated intravascular coagulation (DIC), a complication of severe shock, but not in early compensatory stages. The body prioritizes vasoconstriction and fluid conservation, with no direct link to petechial formation in this phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elevated troponin is a strong indicator of myocardial infarction, reflecting massive cardiac cell destruction. Troponins are proteins released from damaged cardiomyocytes during ischemia. Their high specificity for cardiac muscle makes them a key biomarker for diagnosing acute myocardial infarction, as levels rise within hours of cell death.
Choice B reason: Decreased hemoglobin indicates anemia or blood loss but is not specific to massive cell destruction in myocardial infarction. It may occur secondary to chronic conditions or bleeding but does not directly reflect acute cardiac tissue damage, unlike troponin, which is a precise marker of cardiomyocyte necrosis.
Choice C reason: Elevated creatinine reflects renal dysfunction, not massive cell destruction in myocardial infarction. It indicates impaired kidney filtration, often due to hypoperfusion or chronic disease. While shock from infarction may cause secondary renal injury, creatinine is not a direct marker of cardiac cell death, unlike troponin.
Choice D reason: Decreased sodium (hyponatremia) may occur in heart failure or fluid overload but is not a marker of massive cell destruction. It reflects electrolyte imbalance, not tissue necrosis. In myocardial infarction, sodium levels are typically unaffected unless complicated by other conditions, making it irrelevant to acute cardiac damage.
Correct Answer is ["C","E"]
Explanation
Choice A reason: Flushing the catheter system daily is not recommended for CAUTI prevention. It disrupts the closed system, increasing the risk of introducing pathogens into the bladder. Maintaining a sterile, closed drainage system is critical to prevent bacterial entry, and flushing is only indicated for specific blockages, not routine care.
Choice B reason: Obtaining a urine specimen for culture every 24 hours is not a preventive measure for CAUTI. Routine culturing is unnecessary unless infection is suspected, as it increases manipulation of the catheter system, risking contamination. Cultures are diagnostic, not preventive, and frequent sampling may introduce bacteria, counteracting infection control efforts.
Choice C reason: Securing the catheter prevents movement, reducing trauma to the urethra and bladder mucosa. Movement can cause microtears, allowing bacterial entry and colonization, leading to CAUTI. Proper anchoring ensures the catheter remains stable, minimizing irritation and maintaining the integrity of the urinary tract’s natural barriers against infection.
Choice D reason: Inspecting urine for color, odor, and consistency monitors for signs of infection but does not prevent CAUTI. Changes like cloudiness or foul odor indicate an existing infection, not prevention. While useful for early detection, it is a reactive measure, not a proactive intervention to reduce the incidence of catheter-related infections.
Choice E reason: Maintaining a closed drainage system is critical for CAUTI prevention. A closed system minimizes bacterial entry into the catheter and bladder by preventing disconnection or external contamination. Breaks in the system, such as during bag changes, increase infection risk, making this a key intervention to reduce pathogen introduction.
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