In the plan of care, the most important intervention for a patient experiencing shock is assessing:

Respirations rate.

Heart rate.

Blood pressure.

Temperature.

Answer and Explanation

The Correct Answer is C

A) Respirations rate:
Respiratory rate is an important vital sign to monitor in patients with shock, as respiratory distress can indicate inadequate oxygenation. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

B) Heart rate:
Heart rate is an important vital sign to monitor in patients with shock, as tachycardia (rapid heart rate) may indicate the body's compensatory response to maintain cardiac output and tissue perfusion. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

C) Blood pressure.
In shock, the body's vital organs are not receiving adequate blood flow and oxygen, leading to a life-threatening condition. While all vital signs are important to monitor in a patient experiencing shock, blood pressure is typically considered the most critical because it reflects the perfusion pressure—the force driving blood through the circulatory system to deliver oxygen and nutrients to the body's tissues. A decrease in blood pressure can indicate inadequate tissue perfusion and impending organ failure. Therefore, timely assessment and monitoring of blood pressure are essential for identifying and managing shock effectively.

D) Temperature:
Temperature monitoring is important in assessing for signs of infection or other systemic issues that may contribute to shock, such as sepsis. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

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Correct Answer is D

Explanation

A) Cardiogenic shock:
Cardiogenic shock occurs when the heart is unable to pump enough blood to meet the body's needs, often due to myocardial infarction (heart attack) or other conditions affecting the heart's function. The client's history of a recent infection does not align with the etiology of cardiogenic shock.

B) Neurogenic shock:
Neurogenic shock occurs due to dysfunction of the autonomic nervous system, typically as a result of spinal cord injury or severe brain injury. It is characterized by widespread vasodilation and bradycardia. The client's history of a recent infection does not align with the etiology of neurogenic shock.

C) Hypovolemic shock:
Hypovolemic shock occurs due to a significant loss of blood volume, such as from trauma, hemorrhage, or dehydration. While infection can lead to fluid loss and dehydration in some cases, the client's history of a recent infection suggests a different etiology, specifically septic shock, which is driven by the systemic inflammatory response to infection.

D) Septic shock.
Septic shock is a type of distributive shock caused by a systemic response to infection. It occurs when an infection triggers a widespread inflammatory response, leading to vasodilation, increased capillary permeability, fluid loss from the bloodstream, and impaired tissue perfusion. The client's history of a recent infection suggests that the shock may be septic in nature.

A. The amount of blood pumped by the heart through the circulatory system in 1 minute. B. Smooth muscle movement of the GI tract by way of contractions. C. Neutralization by use of bicarbonate from pancreatic and biliary secretions. D. It is the process when food is broken down into molecules that can be absorbed.

Correct Answer is D

Explanation

A) The amount of blood pumped by the heart through the circulatory system in 1 minute.
This statement describes cardiac output, which is the volume of blood pumped by the heart in one minute. Cardiac output is not directly related to the process of digestion.

B) Smooth muscle movement of the GI tract by way of contractions.
This statement describes peristalsis, which is the rhythmic contraction of smooth muscles in the GI tract that propels food and digestive contents through the digestive system. While peristalsis is an essential aspect of digestion, it does not encompass the entire process.

C) Neutralization by use of bicarbonate from pancreatic and biliary secretions.
This statement describes the role of bicarbonate in neutralizing stomach acid in the small intestine. Bicarbonate is released from pancreatic and biliary secretions to neutralize acidic chyme from the stomach, creating a more favorable environment for digestive enzymes to function. While this is an important aspect of digestion, it does not fully encompass the entire process.

D) It is the process when food is broken down into molecules that can be absorbed.
Digestion refers to the process by which food is broken down into smaller molecules that can be absorbed and utilized by the body. This process occurs in the gastrointestinal (GI) tract and involves the mechanical and chemical breakdown of food into nutrients such as carbohydrates, proteins, and fats, as well as vitamins and minerals. These nutrients are then absorbed across the lining of the GI tract and transported to cells throughout the body for energy, growth, and repair.

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In the plan of care, the most important intervention for a patient experiencing shock is assessing:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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