The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8°F oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?
Septic
Hypovolemic
Cardiogenic
Anaphylactic
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
In a state of shock, the body prioritizes blood flow to vital organs such as the myocardium (heart muscle) and the brain. This is because these organs are essential for survival, and their function is critical. The body's compensatory mechanisms ensure that blood is diverted to these areas to maintain their perfusion, even at the expense of less vital organs.
Choice B reason:
The pulmonary vasculature, which involves the blood vessels of the lungs, is important for gas exchange but is not specifically prioritized in the same way that the myocardium and brain are during shock. While maintaining adequate oxygenation is crucial, the body’s immediate focus is on sustaining the heart and brain.
Choice C reason:
The small and large bowel are not considered high-priority organs during shock. Blood flow to the gastrointestinal tract can be reduced to preserve perfusion to more vital organs. This reduced blood flow can result in decreased bowel activity and hypoactive bowel sounds.
Choice D reason:
While the hepatic (liver) and renal (kidneys) vasculature are important for detoxification and fluid balance, they are not prioritized over the heart and brain during shock. Reduced perfusion to these organs can lead to liver and kidney dysfunction, but the immediate priority is ensuring the survival of the heart and brain.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.