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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Anorexia and nausea are common symptoms in many illnesses, including septic shock, but they are not specific late signs. These symptoms can occur early in the disease process and are not definitive indicators of the severity of the condition.
Choice B reason:
Generalized malaise, a feeling of overall discomfort and fatigue, is a nonspecific symptom that can occur in many conditions, including septic shock. It is not a specific late sign and can be present at various stages of the illness.
Choice C reason:
Slowed, shallow respirations can be a sign of respiratory failure, which can occur in severe sepsis or septic shock. However, it is not a specific late sign of septic shock itself. Respiratory patterns can vary depending on the underlying cause and progression of the shock.
Choice D reason:
Decreased temperature, or hypothermia, is a late sign of septic shock. As the body’s compensatory mechanisms fail, the ability to maintain normal body temperature is impaired. This can result in hypothermia, indicating severe and advanced septic shock. The body's metabolic processes slow down, and the overall prognosis becomes poorer as hypothermia sets in.
Correct Answer is B
Explanation
Choice A reason: Decreased systemic vascular resistance, decreased CVP. In hypovolemic shock, the body compensates by increasing systemic vascular resistance to maintain blood pressure. Therefore, decreased systemic vascular resistance is not consistent with hypovolemic shock. Central venous pressure (CVP) would be low due to reduced blood volume.
Choice B reason: Increased systemic vascular resistance, decreased CVP. Hypovolemic shock is characterized by low blood volume, leading to decreased cardiac output and low CVP. The body compensates by increasing systemic vascular resistance to maintain blood pressure, making this the correct answer.
Choice C reason: Increased systemic vascular resistance, increased CVP. While systemic vascular resistance increases, CVP is typically decreased in hypovolemic shock due to the lack of circulating blood volume.
Choice D reason: Decreased systemic vascular resistance, increased CVP. Decreased systemic vascular resistance and increased CVP are not consistent with hypovolemic shock. These parameters might be seen in conditions with different hemodynamic profiles.
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