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 A

Explanation

Choice A reason: Epinephrine. Epinephrine is the first-line treatment for anaphylactic shock. It rapidly reverses severe allergic reactions by reducing swelling, increasing blood pressure, and improving breathing.

Choice B reason: Rapid infusion of normal saline. While fluid resuscitation is important in managing anaphylactic shock, it is not the initial therapy of choice. Epinephrine should be administered first to counteract the allergic reaction.

Choice C reason: Dobutamine. Dobutamine is used to support cardiac function in certain types of shock but is not the first-line treatment for anaphylactic shock.

Choice D reason: Norepinephrine. Norepinephrine is a vasopressor used to treat severe hypotension and shock but is not the initial treatment for anaphylactic shock. Epinephrine is preferred to address the allergic reaction.

A. Cool, moist skin. B. Increased bowel sounds. C. Restlessness. D. Increased respiratory rate. E. Decreased blood glucose.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Cool, moist skin. Cool, moist skin is an early sign of shock as the body redirects blood flow away from the skin to vital organs. This is part of the body's compensatory mechanisms to maintain perfusion.

Choice B reason: Increased bowel sounds. Bowel sounds typically decrease during shock due to reduced blood flow to the gastrointestinal tract. Increased bowel sounds would not be expected.

Choice C reason: Restlessness. Restlessness is an early sign of shock indicating reduced oxygen delivery to the brain. The body responds by becoming more alert and anxious, reflecting increased sympathetic nervous system activity.

Choice D reason: Increased respiratory rate. An increased respiratory rate is a compensatory mechanism to improve oxygenation and reduce carbon dioxide levels in the blood. This is common in the early stages of shock.

Choice E reason: Decreased blood glucose. Blood glucose levels are generally not an immediate indicator in the early stages of shock. The body's stress response can actually increase blood glucose levels initially.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the initial therapy of choice for the treatment of anaphylactic shock?

Correct Answer is A

Explanation

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.)

Correct Answer is ["A","C","D"]

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.

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

The nurse understands that which hemodynamic parameters are consistent with hypovolemic shock? Decreased cardiac output and:

What is an integumentary manifestation of anaphylactic 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 a late sign of septic shock?

Cardiac output (CO) equals:

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