The nurse is caring for a patient who is experiencing shock. What finding would the nurse expect when assessing the abdomen?
Hyperactive bowel sounds
Diffuse tenderness upon palpation
Hypoactive bowel sounds
Evidence of Cullen's sign
The Correct Answer is C
Choice A reason:
Hyperactive bowel sounds are not typically associated with shock. Shock, particularly in its later stages, often leads to reduced perfusion to the gastrointestinal tract, which can cause decreased bowel activity. Hyperactive bowel sounds might be seen in other conditions such as gastrointestinal infections or bowel obstructions but are not characteristic of shock.
Choice B reason:
Diffuse tenderness upon palpation can be seen in various abdominal conditions, such as peritonitis or appendicitis, but it is not a hallmark sign of shock. While abdominal tenderness can occur if the patient has experienced trauma to the abdomen, it is not a primary sign used to diagnose shock.
Choice C reason:
Hypoactive bowel sounds are a common finding in patients experiencing shock. As the body prioritizes blood flow to vital organs like the brain and heart, blood flow to the gastrointestinal tract is reduced, leading to decreased bowel activity. This is consistent with the body's physiological response to shock and makes hypoactive bowel sounds the correct choice.
Choice D reason:
Cullen's sign, which is bruising around the umbilicus, is indicative of intra-abdominal bleeding, such as from pancreatitis or ruptured ectopic pregnancy. It is not a general sign of shock and would not be expected in all shock patients. Therefore, Cullen's sign is not the correct answer in this context.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Septic shock is caused by severe infections leading to systemic inflammation and vasodilation. Symptoms often include fever, increased heart rate, low blood pressure, and signs of infection. While the vital signs in this scenario include tachycardia and hypotension, there is no indication of infection, fever, or other signs that would suggest sepsis as the primary cause of the shock.
Choice B reason:
Hypovolemic shock results from a significant loss of blood or fluids, common in traumatic injuries. The patient's tachycardia, hypotension, and decreased pulse oximetry indicate a possible significant blood loss due to the trauma from the motor vehicle accident. These signs are typical for hypovolemic shock, making it the most likely diagnosis given the context.
Choice C reason:
Cardiogenic shock is caused by the heart's failure to pump effectively, often due to myocardial infarction or heart disease. While hypotension and tachycardia are present, there are no other indicators, such as chest pain or history of heart disease, to suggest that the patient's shock is cardiogenic in nature. The context of a traumatic accident points more towards hypovolemic shock.
Choice D reason:
Anaphylactic shock is a severe allergic reaction causing widespread vasodilation and bronchoconstriction. Symptoms include sudden hypotension, tachycardia, and difficulty breathing. There is no mention of an allergen exposure or typical allergic reactions (such as rash, itching, or swelling) in the patient's history, making anaphylactic shock an unlikely cause of the symptoms described.
Correct Answer is D
Explanation
Choice A reason:
Severe blood loss due to trauma can lead to hypovolemic shock, a specific type of shock. However, this description is not comprehensive enough to cover the pathophysiology of all types of shock. Shock involves various mechanisms and can occur due to different underlying causes beyond just blood loss, such as cardiac failure, infections, or neurological issues.
Choice B reason:
Catatonia is a state of psychomotor immobility and behavioral abnormality stemming from psychological disturbances, not a direct feature of shock. While mental status changes can be a symptom of shock, catatonia itself is not a defining characteristic of the condition. The pathophysiology of shock involves physiological imbalances rather than purely psychological disturbances.
Choice C reason:
Tachycardia (increased heart rate) and hypotension (low blood pressure) are symptoms that can occur during shock, but they do not describe the underlying pathophysiology. These signs are the body's response to the decreased perfusion and oxygen delivery to tissues. The fundamental issue in shock is the failure to meet the body's metabolic demands due to impaired oxygen delivery, which is better captured by another option.
Choice D reason:
An imbalance between oxygen supply and demand is the core issue in all types of shock. Whether due to blood loss, heart failure, or systemic infection, shock results in insufficient oxygen delivery to meet the needs of tissues and organs. This imbalance leads to cellular hypoxia and subsequent organ dysfunction, encapsulating the essential pathophysiological process of shock.
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