The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

Limited gas exchange

Multiple organ failure

Endotoxins in the system

Brain death

Answer and Explanation

The Correct Answer is B

A. Limited gas exchange: Impaired gas exchange occurs in earlier stages of shock due to poor perfusion and fluid accumulation, especially in the lungs. While serious, it is typically one component and not the final pathway leading to death.
B. Multiple organ failure: Irreversible shock leads to widespread cellular death and systemic hypoperfusion, causing failure of multiple organ systems. Once multiple organs shut down, the body can no longer sustain life due to failure of the body's compensatory mechanisms, and recovery is no longer possible.
C. Endotoxins in the system: Endotoxins may be present in septic shock and can contribute to inflammation and organ damage. However, their presence alone does not define the terminal stage of shock without resulting in systemic organ failure.
D. Brain death: Brain death may result from prolonged hypoxia or trauma, but it is not the defining feature of irreversible shock. In this stage, death results from the collapse of multiple organ systems rather than isolated neurological failure.

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Correct Answer is A

Explanation

A. Population of African descent: Individuals of African descent have a higher prevalence of hypertension, often developing it at a younger age and experiencing more severe complications. Early screening is essential for prevention and management.
B. Japanese population: While hypertension can occur, it tends to present later and may be more influenced by dietary factors such as sodium intake rather than genetics alone.
C. Mexican population: This group may be at risk due to obesity or lifestyle factors, but the risk is generally not as early or as severe as in African descent populations.
D. Asian population: Asians may develop hypertension, but it typically occurs at older ages and is not as strongly associated with early onset as seen in African descent populations.

A. "Chest pain should always be evaluated." B. "But you are okay now." C. "It must have been frightening for you." D. "We would not let you die."

Correct Answer is C

Explanation

A. "Chest pain should always be evaluated.": While true, this response shifts focus away from the client’s emotional experience. It is more clinical than empathetic, and may not validate the client's current distress.
B. "But you are okay now.": This can feel dismissive of the intense fear the client experienced. While intended to reassure, it overlooks the need for emotional validation during recovery from a panic attack.
C. "It must have been frightening for you.": This statement acknowledges and validates the client’s emotional experience. Empathic reflection helps reduce shame and fosters therapeutic rapport during an anxiety crisis.
D. "We would not let you die.": This response may sound comforting but unintentionally minimizes the client’s perceived fear and lacks therapeutic depth. It doesn’t address the emotional intensity of the situation.

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The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

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Naxlex Comprehensive Predictor Exams

The nurse would screen a client from which ethnic background for hypertension at an early age?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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