A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

The client has metabolic alkalosis and warm extremities

The client develops bradycardia and bradypnea

The client has hypotension and is confused

The client has hypertension and anuria

Answer and Explanation

The Correct Answer is C

A. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically indicative of postoperative shock. Metabolic alkalosis may be caused by excessive vomiting or prolonged gastric suctioning, but it is not a hallmark sign of shock. Warm extremities may suggest adequate peripheral perfusion rather than impaired perfusion seen in shock.

B. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) may occur as compensatory mechanisms in certain types of shock, such as neurogenic shock. However, they are not specific indicators of postoperative shock. Tachycardia (rapid heart rate) and tachypnea (rapid respiratory rate) are more common findings in most types of shock, including postoperative shock.

C. The client has hypotension and is confused: Hypotension (low blood pressure) and confusion are classic signs of shock, including postoperative shock. Hypotension indicates inadequate perfusion of vital organs, while confusion may result from cerebral hypoperfusion. Altered mental status, such as confusion, is a significant neurological manifestation of shock.

D. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (decreased urine output) are not typical manifestations of postoperative shock. Hypertension may occur in certain conditions that can lead to shock, such as septic shock, during the compensatory phase. However, it is not a primary sign of shock. Anuria may occur in cases of severe hypovolemic shock but is not specific to postoperative shock.

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Correct Answer is C

Explanation

A. Marfan's syndrome: Marfan's syndrome is a genetic disorder that affects the connective tissue in the body, predisposing individuals to various cardiovascular, skeletal, and ocular abnormalities. While Marfan's syndrome can present with certain cranial and intracranial manifestations, such as dural ectasia and intracranial aneurysms, it is not typically considered a direct risk factor for traumatic brain injury (TBI).

B. Hypercarbia: Hypercarbia refers to elevated levels of carbon dioxide (CO2) in the blood. While severe hypercarbia can lead to cerebral vasodilation and potentially exacerbate intracranial pressure in individuals with traumatic brain injury, it is not considered a direct risk factor for TBI itself.

C. Falls: Falls are a significant risk factor for traumatic brain injury (TBI), particularly in older adults and young children. Falls can occur due to various factors such as environmental hazards, impaired mobility, balance issues, or neurological conditions. Falls are a leading cause of TBI-related emergency department visits, hospitalizations, and fatalities.

D. Ventriculostomy: Ventriculostomy involves the placement of a catheter into the ventricular system of the brain to monitor intracranial pressure (ICP) or drain cerebrospinal fluid (CSF). While ventriculostomy is a procedure commonly performed in the management of severe traumatic brain injury to monitor and manage intracranial pressure, it is not a risk factor for TBI itself.

A. Open-angle glaucoma B. Macular degeneration C. Meniere’s disease D. Retinal detachment

Correct Answer is D

Explanation

A. Open-angle glaucoma: Open-angle glaucoma typically presents with increased intraocular pressure and gradual loss of peripheral vision, not with bright flashes of light and dark floating spots.

B. Macular degeneration: Macular degeneration is characterized by central vision loss, not by bright flashes of light and dark floating spots.

C. Meniere’s disease: Meniere’s disease is a disorder of the inner ear characterized by episodes of vertigo, hearing loss, and tinnitus. It does not typically cause bright flashes of light and dark floating spots in the visual field.

D. Retinal detachment: Trauma, such as being tackled while playing football, can lead to retinal detachment, which can manifest with symptoms such as bright flashes of light (photopsia) and dark floating spots (floaters) in the affected eye. This condition is considered a medical emergency and requires prompt evaluation and treatment to prevent permanent vision loss.

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A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a risk factor for TBI?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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