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 A

Explanation

Choice A rationale
Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.
Choice B rationale
A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.
Choice C rationale
A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.
Choice D rationale
Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.

A. Decreased breath sounds in the lower lobes. B. Increased respiratory rate and use of accessory muscles. C. Elevated blood pressure and heart rate. D. Presence of wheezing and cyanosis.

Correct Answer is B

Explanation

Choice A rationale
Decreased breath sounds in the lower lobes can indicate areas of the lung that are not ventilating well, but this finding alone does not specifically indicate an exacerbation of COPD. It could be due to other conditions such as pleural effusion or atelectasis.
Choice B rationale
Increased respiratory rate and use of accessory muscles are signs of respiratory distress and indicate that the patient is working harder to breathe. These findings are consistent with an exacerbation of COPD, where the airways are more obstructed, and the patient has difficulty maintaining adequate ventilation.
Choice C rationale
Elevated blood pressure and heart rate can occur in many conditions and are not specific indicators of a COPD exacerbation. These vital sign changes can be due to pain, anxiety, or other stressors.
Choice D rationale
Presence of wheezing and cyanosis are also indicators of a COPD exacerbation. Wheezing indicates airway obstruction, and cyanosis indicates hypoxemia, both of which are common during an exacerbation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?

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