In a patient with septic shock, which complication will the nurse remain alert for?
Neurogenic shock.
Febrile seizures.
Esophageal varices.
Acute Respiratory Distress Syndrome.
The Correct Answer is D
Choice A reason: Neurogenic shock is a type of distributive shock that occurs due to a sudden loss of sympathetic nervous system signals to the smooth muscle in vessel walls. It is not a direct complication of septic shock, which is primarily caused by severe infection and systemic inflammation. While both are forms of shock, the mechanisms and causes are different.
Choice B reason: Febrile seizures are typically seen in children with high fevers and are not a common complication of septic shock in adults. Septic shock involves severe infection and systemic inflammatory response, leading to complications such as organ failure rather than febrile seizures.
Choice C reason: Esophageal varices are enlarged veins in the esophagus that can bleed, often seen in patients with liver disease and portal hypertension. They are not a complication of septic shock. While severe infection and systemic inflammation can lead to various complications, esophageal varices are specifically related to liver pathology.
Choice D reason: Acute Respiratory Distress Syndrome (ARDS) is a severe complication that the nurse should remain alert for in patients with septic shock. ARDS is characterized by rapid onset of widespread inflammation in the lungs, leading to respiratory failure. It is a common and serious complication of septic shock due to the systemic inflammatory response affecting the lung tissue. Early recognition and management are crucial for improving patient outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A heart rate of 56/min and a blood pressure of 110/70, while slightly lower than normal, may not require immediate intervention unless accompanied by other symptoms. Bradycardia (a slow heart rate) and this blood pressure reading can be within acceptable limits for some individuals, especially if they are asymptomatic.
Choice B reason: Mitral valve regurgitation with a thready peripheral pulse indicates a decrease in cardiac output, which can be concerning. However, it may not require immediate intervention unless the client shows signs of severe decompensation or other critical symptoms. Continuous monitoring and evaluation are essential, but immediate action might not be necessary.
Choice C reason: Chest pain with inspiration in a client with pericarditis can be a symptom of the condition itself, which involves inflammation of the pericardium. While pain management and monitoring are important, this symptom alone may not necessitate immediate intervention unless it is severe or accompanied by other alarming signs.
Choice D reason: The development of slurred speech in a client with a history of atrial fibrillation is a critical symptom that warrants immediate intervention. Slurred speech can be a sign of a stroke or transient ischemic attack (TIA), both of which require urgent medical attention. Immediate action is needed to evaluate and manage the client's condition to prevent further complications.
Correct Answer is B
Explanation
Choice A reason: The rehabilitative phase of burn care focuses on restoring function, improving cosmetic appearance, and achieving the best possible quality of life for the patient. This phase typically begins after the wound has healed and continues for months to years. The care priorities mentioned, such as wound care and nutritional support, indicate that the patient is still in a more active phase of treatment rather than the long-term rehabilitative phase.
Choice B reason: The acute phase of burn care starts after the initial resuscitation and continues until the wound is closed. During this phase, the primary focus is on wound care, nutritional support, and prevention of complications like infection. The goal is to promote healing, prevent infection, and address the patient's nutritional needs to support recovery. This phase aligns with the care priorities mentioned in the question.
Choice C reason: The emergent phase, also known as the resuscitative phase, begins at the time of injury and continues for the first 24-48 hours. The primary focus during this phase is on stabilizing the patient's condition, managing airway and breathing, fluid resuscitation, and addressing immediate life-threatening issues. The care priorities in the question indicate that the patient has moved beyond the initial resuscitative efforts.
Choice D reason: The immediate resuscitative phase overlaps with the emergent phase and focuses on providing immediate life-saving measures to stabilize the patient. This includes fluid resuscitation, airway management, and treating shock. The care priorities mentioned in the question suggest that the patient is beyond the initial resuscitative efforts and is in a more ongoing phase of treatment.
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