Which clinical manifestation indicates worsening in the condition of a client in the refractory phase of shock?

Urine concentrated with output of 30mL/hr

Skin that is hot to touch and diaphoretic

Tachypnea with respiratory rate of 28

Oozing and bleeding from multiple IV sites

Answer and Explanation

The Correct Answer is D

Choice A reason: A urine output of 30 mL/hr is the minimum acceptable threshold for renal perfusion. While concentrated urine indicates compensation or early injury, it does not characterize the end-stage "refractory" phase where multisystem organ failure and total renal shutdown typically occur.

Choice B reason: Skin that is hot and diaphoretic is often seen in the early "warm" phase of septic shock. In the refractory phase, the skin is typically cold, mottled, and cyanotic due to extreme peripheral vasoconstriction and the total failure of the circulatory system.

Choice C reason: A respiratory rate of 28 is tachypneic and indicates the compensatory or progressive stage of shock as the body attempts to manage metabolic acidosis. In the refractory phase, respiratory failure usually progresses to agonal breathing or requires total mechanical ventilatory support.

Choice D reason: Oozing from IV sites is a classic sign of Disseminated Intravascular Coagulation (DIC), which frequently occurs in the refractory stage of shock. In this phase, the exhaustion of clotting factors and platelets leads to uncontrolled systemic bleeding, signaling that the shock has become irreversible.

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Correct Answer is A

Explanation

Choice A reason: Cardiogenic shock occurs when the heart’s muscular wall fails to pump effectively. A myocardial infarction (MI) causes necrosis of the cardiac tissue; if more than 40% of the left ventricle is damaged, the heart cannot maintain adequate cardiac output, leading directly to cardiogenic shock.

Choice B reason: A client with trauma-related blood loss is at risk for hypovolemic shock. This type of shock is caused by a lack of intravascular volume rather than a primary failure of the heart muscle itself, distinguishing it from the pump-failure mechanism of cardiogenic shock.

Choice C reason: A tension pneumothorax causes obstructive shock. The high pressure in the thoracic cavity shifts the mediastinum and compresses the great vessels (superior and inferior vena cava), physically preventing blood from returning to the heart, which is different from a primary muscular failure.

Choice D reason: A client with positive blood cultures is at risk for septic shock. This is a form of distributive shock caused by systemic vasodilation and increased capillary permeability in response to an overwhelming infection, rather than an initial failure of the cardiac pump.

A. Pain B. Laryngeal edema C. Leukopenia D. Fluid volume deficit

Correct Answer is C

Explanation

Choice A reason: Pain is a significant concern in partial-thickness burns because the nerve endings remain intact but are exposed and irritated. Managing severe pain is a priority in the emergent phase to reduce the physiological stress response and improve the patient's comfort and cooperation with treatment.

Choice B reason: Laryngeal edema is a critical priority, especially with burns to the head and neck. Inhalation of hot gases or steam can cause rapid airway swelling and obstruction. Ensuring airway patency is the "A" in the ABCs of trauma and burn management during the emergent phase.

Choice C reason: Leukopenia, or a low white blood cell count, is not a primary concern in the first few hours (emergent phase). In fact, the initial stress response often causes a transient increase in white blood cells (leukocytosis). Infection and changes in WBC counts are typically concerns during the later acute phase.

Choice D reason: Fluid volume deficit is a major concern due to the massive shift of fluids from the intravascular to the interstitial space. Aggressive fluid resuscitation is required during the first 24 to 48 hours to prevent burn shock and maintain vital organ perfusion.

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Which clinical manifestation indicates worsening in the condition of a client in the refractory phase of shock?

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Naxlex Comprehensive Predictor Exams

Which client is at the greatest risk of developing cardiogenic shock?

Correct Answer is A

Explanation

A nurse is caring for a client during the first few hours post-admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of the burn injury?

Correct Answer is C

Explanation

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