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","C","D"]

Explanation

Choice A reason: Cool, moist skin. Cool, moist skin is an early sign of shock as the body redirects blood flow away from the skin to vital organs. This is part of the body's compensatory mechanisms to maintain perfusion.

Choice B reason: Increased bowel sounds. Bowel sounds typically decrease during shock due to reduced blood flow to the gastrointestinal tract. Increased bowel sounds would not be expected.

Choice C reason: Restlessness. Restlessness is an early sign of shock indicating reduced oxygen delivery to the brain. The body responds by becoming more alert and anxious, reflecting increased sympathetic nervous system activity.

Choice D reason: Increased respiratory rate. An increased respiratory rate is a compensatory mechanism to improve oxygenation and reduce carbon dioxide levels in the blood. This is common in the early stages of shock.

Choice E reason: Decreased blood glucose. Blood glucose levels are generally not an immediate indicator in the early stages of shock. The body's stress response can actually increase blood glucose levels initially.

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

Which assessment findings indicate to the nurse that a client is exhibiting early clinical manifestations of the compensatory stage of shock? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The compensatory stage of shock results in what assessment findings?

Correct Answer is A

Explanation

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