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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Hypotension, or low blood pressure, is a common feature in all types of shock, including hypovolemic, cardiogenic, and septic shock. It is not specific to neurogenic shock and therefore does not help in distinguishing it from other forms of shock.

Choice B reason:

A change in mental status, such as confusion or decreased consciousness, can occur in many types of shock due to decreased cerebral perfusion. This symptom is not unique to neurogenic shock and can be seen in hypovolemic, cardiogenic, and septic shock as well.

Choice C reason:

Bradycardia, or a slow heart rate, is a hallmark of neurogenic shock. This occurs due to disruption of the sympathetic nervous system, which normally maintains a higher heart rate through sympathetic stimulation. In neurogenic shock, the loss of sympathetic tone leads to unopposed parasympathetic activity, resulting in bradycardia. This is in contrast to other forms of shock, which typically present with tachycardia.

Choice D reason:

Warm, edematous skin is not typically associated with neurogenic shock. This symptom may be more relevant in septic shock, where widespread vasodilation can lead to warm skin. However, it is not specific enough to distinguish neurogenic shock from other types of shock.

A. Hyperactive bowel sounds B. Diffuse tenderness upon palpation C. Hypoactive bowel sounds D. Evidence of Cullen's sign

Correct Answer is C

Explanation

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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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?

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Naxlex Comprehensive Predictor Exams

What clinical manifestation distinguishes or separates neurogenic shock from other forms of shock?

Correct Answer is C

Explanation

The nurse is caring for a patient who is experiencing shock. What finding would the nurse expect when assessing the abdomen?

Correct Answer is C

Explanation

Cardiogenic shock occurs when the heart's pumping ability is compromised. What can impair the pumping ability of the heart? Select all that apply.

The nurse working in the ICU is receiving a client diagnosed with late septic shock. The nurse correlates which clinical manifestations to this stage of septic shock?

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?

Which assessment findings indicate to the nurse that a client is exhibiting early clinical manifestations of the compensatory stage of shock? (Select all that apply.)

What is a late sign of septic shock?

The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8 oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?

The nurse is caring for a patient recovering from surgery. What action should the nurse perform to prevent the onset of hypovolemic shock?

What is an integumentary manifestation of anaphylactic shock?