Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

Respiratory rate is 26.

+1 pedal pulses.

Body temperature is 36.8°C (rectal).

Urine output is greater than 40 cc/hr.

Answer and Explanation

The Correct Answer is D

Choice A reason:

While an increased respiratory rate can indicate a compensatory response to shock, it does not directly measure tissue perfusion. It suggests the body is attempting to improve oxygen delivery, but it is not a definitive indicator of adequate tissue perfusion.

Choice B reason:

+1 pedal pulses can indicate decreased perfusion to the extremities, but they do not provide comprehensive information about overall tissue perfusion. Peripheral pulses can be weak in shock due to vasoconstriction and poor circulation, but they are not the most reliable indicator of tissue perfusion.

Choice C reason:

Body temperature is not a direct measure of tissue perfusion. While it is important to monitor, changes in temperature can result from various factors and do not specifically reflect the adequacy of tissue perfusion.

Choice D reason:

Urine output greater than 40 cc/hr is a key indicator of adequate tissue perfusion. The kidneys are highly sensitive to changes in perfusion, and adequate urine output suggests that the kidneys are receiving sufficient blood flow to filter and excrete waste products. Monitoring urine output is a standard practice in assessing tissue perfusion and overall fluid balance in shock patients.

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Correct Answer is A

Explanation

Choice A reason:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

A. Apply tight-fitting clothing B. Complete frequent skin checks C. Initiate a bowel regimen program D. Insert an indwelling Foley catheter E. Restrict all patient visitors

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

Explanation

Choice A reason:

Applying tight-fitting clothing is not recommended for patients at risk of autonomic dysreflexia. Tight clothing can be a trigger for this condition by causing discomfort and potentially leading to an exaggerated autonomic response.

Choice B reason:

Completing frequent skin checks is crucial in preventing autonomic dysreflexia. Skin irritation, pressure sores, and other integumentary issues can trigger autonomic responses. Regular assessments help in early identification and prevention of potential irritants.

Choice C reason:

Initiating a bowel regimen program is essential for preventing autonomic dysreflexia. Constipation or bowel distension can be potent triggers for this condition. A consistent bowel program helps in managing and preventing these issues.

Choice D reason:

Inserting an indwelling Foley catheter is recommended to manage bladder distention, a common trigger of autonomic dysreflexia. Continuous bladder drainage prevents overdistention and reduces the risk of triggering autonomic responses.

Choice E reason:

Restricting all patient visitors is unnecessary for preventing autonomic dysreflexia. While a calm environment can be beneficial, visitor restriction is not directly related to managing the risk of this specific condition.

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Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Correct Answer is A

Explanation

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

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

Explanation

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