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?
Tachycardia.
Lethargic mental status.
Anuria.
Normal blood pressure.
Warm flushed skin.
Correct Answer : A,B,C
Choice A reason: Tachycardia. In late septic shock, the body attempts to compensate for poor perfusion and low blood pressure by increasing the heart rate. Tachycardia is a common finding as the heart tries to pump more blood to the tissues.
Choice B reason: Lethargic mental status. As septic shock progresses, decreased perfusion to the brain can lead to changes in mental status, such as lethargy or confusion. This reflects the severity of the condition and the impact on the central nervous system.
Choice C reason: Anuria. Anuria, or the absence of urine output, occurs in late septic shock due to severe hypoperfusion and failure of the kidneys. It is a critical sign indicating that the body's organs are shutting down.
Choice D reason: Normal blood pressure. In late septic shock, blood pressure is typically very low due to systemic vasodilation and fluid loss. Normal blood pressure would not be expected at this advanced stage.
Choice E reason: Warm flushed skin. Warm flushed skin is associated with the early stages of septic shock when vasodilation leads to increased blood flow to the skin. In late septic shock, the skin is more likely to be cool and pale due to poor perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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