A nurse is assessing a client who presents with a temperature of 38°C (100.4°F), a heart rate of 110 beats per minute, and a blood pressure of 90/60 mmHg.Which condition is the client most likely experiencing?

Septic shock.

Hypovolemic shock.

Cardiogenic shock.

Neurogenic shock.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Septic shock is characterized by a systemic inflammatory response to infection, leading to vasodilation, increased capillary permeability, and hypotension. The patient’s elevated temperature, tachycardia, and hypotension are consistent with septic shock. In septic shock, the body’s response to infection leads to widespread inflammation and impaired tissue perfusion.
Choice B rationale
Hypovolemic shock is caused by a significant loss of blood or fluids, leading to decreased circulating volume and hypotension. While the patient’s hypotension and tachycardia could be consistent with hypovolemic shock, the elevated temperature suggests an infectious process, making septic shock more likely.
Choice C rationale
Cardiogenic shock is caused by the heart’s inability to pump effectively, leading to decreased cardiac output and tissue perfusion. While hypotension and tachycardia are consistent with cardiogenic shock, the elevated temperature is not a typical finding. Cardiogenic shock is usually associated with conditions like myocardial infarction or severe heart failure.
Choice D rationale
Neurogenic shock is caused by a disruption in the autonomic pathways, leading to vasodilation and hypotension. It is typically associated with spinal cord injuries or severe head trauma. The patient’s elevated temperature and tachycardia are not consistent with neurogenic shock, making septic shock the more likely diagnosis.

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Correct Answer is C

Explanation

Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.

A. The patient who has hyperkalemia and is weak and tired. B. The patient who sometimes experiences chest pain when climbing a flight of stairs. C. The patient who is experiencing persistent and severe chest pain when at rest. D. The patient who has paroxysmal nocturnal dyspnea (PND).

Correct Answer is C

Explanation

Choice A rationale
Hyperkalemia can cause weakness and fatigue, but it is not directly related to acute coronary syndrome (ACS). ACS is primarily associated with chest pain and other cardiac symptoms.
Choice B rationale
Experiencing chest pain when climbing a flight of stairs may indicate stable angina, which is a form of chronic coronary artery disease. However, it does not meet the criteria for ACS, which involves more severe and persistent symptoms.
Choice C rationale
Persistent and severe chest pain when at rest is a hallmark symptom of acute coronary syndrome (ACS). This condition requires immediate medical attention as it can lead to myocardial infarction (heart attack) or other serious complications.
Choice D rationale
Paroxysmal nocturnal dyspnea (PND) is a symptom of heart failure, not acute coronary syndrome (ACS). While heart failure can coexist with ACS, PND alone does not indicate ACS4.

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A nurse is assessing a client who presents with a temperature of 38°C (100.4°F), a heart rate of 110 beats per minute, and a blood pressure of 90/60 mmHg.Which condition is the client most likely experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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