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 D

Explanation

Cushing's Triad is a set of three classic signs associated with increased intracranial pressure (ICP). These signs include hypertension, bradycardia, and irregular respirations. The presence of Cushing's Triad indicates severe brain injury or increased ICP, often leading to brainstem compression.

A. Tachycardia (Option A): Increased intracranial pressure can initially lead to tachycardia as the body attempts to compensate for the changes. However, as ICP continues to rise and brainstem compression occurs, the sympathetic response diminishes, resulting in bradycardia rather than tachycardia. Therefore, Cushing's Triad is not associated with preventing tachycardia.

B. Agonal breathing (Option B): Agonal breathing, characterized by gasping, labored breathing, or irregular breathing patterns, may occur as a result of brainstem dysfunction or damage. Cushing's Triad, indicative of increased ICP and impending brainstem herniation, does not prevent agonal breathing. In fact, irregular respirations are part of Cushing's Triad.

C. Chest pain (Option C): Chest pain may occur due to various cardiac or respiratory conditions and is not directly related to Cushing's Triad or increased intracranial pressure. Therefore, Cushing's Triad does not prevent chest pain.

D. Brainstem ischemia (Option D): Increased intracranial pressure can lead to brainstem compression, compromising blood flow to the brainstem and resulting in brainstem ischemia. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, is a nervous system response indicative of severe brain injury or increased ICP, which can lead to brainstem ischemia if left untreated. Therefore, Cushing's Triad is associated with brainstem ischemia rather than preventing it.

A. "Your heart condition is caused by thickening of the ventricular walls and septum." B. "Your heart condition is caused by excessive stretching of the ventricles." C. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty." D. "Your heart condition is caused from stiffening of the walls of the ventricles." E. Family history of aneurysm

Correct Answer is D

Explanation

A. "Your heart condition is caused by thickening of the ventricular walls and septum." Thickening of the ventricular walls and septum is characteristic of conditions like hypertrophic cardiomyopathy, not pericarditis. This statement does not accurately describe the cause of pericarditis.

B. "Your heart condition is caused by excessive stretching of the ventricles." Excessive stretching of the ventricles is not a typical cause of pericarditis. While stretching of the heart muscle may occur in certain conditions, it is not directly related to pericarditis.

C. "Your heart condition is caused when the ventricular tissue becomes fibrous and fatty." Fibrous and fatty changes in ventricular tissue are features of conditions such as ischemic cardiomyopathy, not pericarditis. This statement does not accurately explain the cause of pericarditis.

D. "Your heart condition is caused from stiffening of the walls of the ventricles." Pericarditis is inflammation of the pericardium, the sac-like membrane surrounding the heart. When the pericardium becomes inflamed, it can stiffen, restricting the heart's movement and leading to chest pain. Therefore, option D accurately explains the cause of pericarditis, attributing it to the stiffening of the pericardium.

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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 collecting neurologic data on a client who has a neurological injury and notes changes suggestive of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent which of the following conditions?

Correct Answer is D

Explanation

A nurse is teaching a client who has pericarditis. Which of the following statements should the nurse include in the client teaching to explain the cause of pericarditis?

Correct Answer is D

Explanation

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