A nurse is assessing a client with a temperature of 39°C (102.2°F) and a blood pressure of 90/60 mmHg. Which condition is the client most likely experiencing?
Septic shock.
Cardiogenic shock.
Neurogenic shock.
Anaphylactic shock.
The Correct Answer is A
Choice A rationale
Septic shock is a severe infection leading to systemic inflammation, characterized by high fever (39°C), low blood pressure (90/60 mmHg), and signs of organ dysfunction. It is a medical emergency requiring immediate intervention.
Choice B rationale
Cardiogenic shock is caused by the heart’s inability to pump blood effectively, leading to hypotension and signs of poor perfusion, but not necessarily high fever.
Choice C rationale
Neurogenic shock results from a disruption in the autonomic pathways, leading to hypotension and bradycardia, but not high fever.
Choice D rationale
Anaphylactic shock is a severe allergic reaction causing hypotension, respiratory distress, and other symptoms, but not typically high fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The absence of burning epigastric pain after eating indicates that the treatment for peptic ulcer disease (PUD) secondary to H. pylori has been effective. This suggests that the ulcer has healed and the inflammation has subsided.
Choice B rationale
Coffee-ground emesis indicates the presence of blood in the vomit, which suggests ongoing bleeding and is not a sign of effective treatment for PUD.
Choice C rationale
A decrease in alcohol intake is beneficial for overall health but does not directly indicate the effectiveness of treatment for PUD secondary to H. pylori.
Choice D rationale
Normalization of hemoglobin levels is important but does not specifically indicate the effectiveness of treatment for PUD secondary to H. pylori. The primary indicator would be the resolution of symptoms such as burning epigastric pain.
Correct Answer is B
Explanation
Choice A rationale
Administering vitamin B12 to increase RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to increase RBC size.
Choice B rationale
Administering vitamin B12 to restore normal RBC maturation is the appropriate action. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency.
Administering vitamin B12 will help restore normal RBC maturation and correct the anemia.
Choice C rationale
Administering medication to decrease RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to decrease RBC size.
Choice D rationale
Administering iron to increase the formation of hemoglobin molecules is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. Iron supplementation is typically used for microcytic anemia, not macrocytic anemia.
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