During the initial stage of shock, which manifestation should the nurse monitor for when assessing the client?

Oliguria.

Hypotension.

Respiratory alkalosis.

Hypoxia.

Answer and Explanation

The Correct Answer is D

Choice A reason: Oliguria. Oliguria, or reduced urine output, is a manifestation that occurs later as shock progresses and renal perfusion decreases. It is not typically seen in the initial stage of shock.

Choice B reason: Hypotension. Hypotension generally appears in the compensatory and progressive stages of shock as the body's compensatory mechanisms begin to fail. In the initial stage, blood pressure may still be maintained by compensatory mechanisms.

Choice C reason: Respiratory alkalosis. Respiratory alkalosis is more likely to occur during the compensatory stage of shock due to hyperventilation as the body attempts to compensate for hypoxia. It is not anticipated in the initial stage of shock.

Choice D reason: Hypoxia. During the initial stage of shock, the body's cells and tissues begin to experience hypoxia due to reduced oxygen delivery. This is an early manifestation that the nurse should monitor for.

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Correct Answer is A

Explanation

Choice A reason: Stroke volume x heart rate. Cardiac output is the volume of blood the heart pumps per minute, calculated by multiplying the stroke volume (the amount of blood ejected with each heartbeat) by the heart rate (the number of beats per minute).

Choice B reason: Afterload x preload. Afterload and preload are important factors influencing cardiac function but do not directly calculate cardiac output. Afterload refers to the resistance the heart must overcome to eject blood, and preload refers to the initial stretching of the heart muscle prior to contraction.

Choice C reason: Ejection fraction x blood pressure. Ejection fraction is a measure of the percentage of blood ejected from the heart with each beat, and blood pressure is the force exerted by circulating blood on the walls of blood vessels. These factors influence cardiac function but do not directly calculate cardiac output.

Choice D reason: Systolic x diastolic BP. Systolic and diastolic blood pressure are measurements of pressure during heartbeats and between beats, respectively. They are not used to calculate cardiac output.

A. Hypotension, rapid thready pulse, cool pale skin. B. Increased urine output. C. Pale, mottled, or cyanotic skin. D. Stupor and loss of reflexes.

Correct Answer is A

Explanation

Choice A reason: Hypotension, rapid thready pulse, cool pale skin. In the compensatory stage of shock, the body attempts to maintain blood pressure and perfusion by increasing the heart rate and constricting blood vessels. Despite these efforts, hypotension can occur, and the skin may become cool and pale due to reduced blood flow to the periphery.

Choice B reason: Increased urine output. In shock, particularly during the compensatory stage, urine output typically decreases as the body attempts to conserve fluids. Increased urine output would not be expected in this context.

Choice C reason: Pale, mottled, or cyanotic skin. These skin changes are more characteristic of the progressive or irreversible stages of shock, indicating severe hypoperfusion and tissue hypoxia. In the compensatory stage, the skin is usually cool and pale, but not yet mottled or cyanotic.

Choice D reason: Stupor and loss of reflexes. These neurological changes are more typical of the later stages of shock when perfusion to the brain is severely compromised. In the compensatory stage, mental status changes may be present but are less severe.

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During the initial stage of shock, which manifestation should the nurse monitor for when assessing the client?

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Naxlex Comprehensive Predictor Exams

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Explanation

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