Which of the following clinical manifestations are suggestive of the systemic inflammatory response syndrome (SIRS)? Select all that apply.

Rationale:

A: Delays airway and breathing by starting with clothing removal and vital signs.

B: Places Foley insertion and clothing removal before IV access and exposure priorities.

C: Begins with vital signs and delays oxygen and airway management, which is unsafe in trauma.
D. This question follows trauma priority care using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).

1. Assess for spontaneous respirations (1)
   This is the first priority. The nurse must immediately determine whether the client is breathing. Without respirations, all other interventions are secondary.
2. Open the airway using chin lift or jaw thrust (7)
   If respirations are compromised or at risk, the airway must be opened next. In trauma, the jaw thrust is preferred to protect the cervical spine.
3. Give supplemental oxygen per mask (2)
   Once the airway is open and breathing is assessed, oxygen is administered to prevent hypoxia, which can rapidly worsen outcomes in trauma patients.
4. Secure/start two large-bore IVs with normal saline (6)
   After airway and breathing are addressed, attention turns to circulation. Large-bore IV access allows for rapid fluid resuscitation to treat or prevent shock.
5. Remove the patient’s clothing (5)
   This step supports exposure, allowing the nurse to fully assess for hidden injuries, bleeding, or deformities. It occurs after life-threatening ABC issues are managed.
6. Obtain a full set of vital signs (4)
   Vital signs are important but should be obtained after immediate threats to airway, breathing, and circulation are controlled.
7. Insert a Foley catheter if not contraindicated (3)
   This is a lower-priority intervention used to monitor urine output and renal perfusion. It should be delayed until the client is stabilized and contraindications (e.g., pelvic trauma) are ruled out.

Rationale:
A. Decreased blood volume is a primary cause of hypovolemic shock. When the body loses blood or plasma, there is insufficient circulating volume to perfuse tissues, leading to cellular hypoxia and organ dysfunction. Causes include hemorrhage, severe dehydration, or fluid loss from burns, all of which reduce oxygen delivery to vital organs.

B. Decreased size of the capillary bed does not cause shock. Shock occurs due to inadequate oxygen delivery to tissues, which results from reduced circulating volume, pump failure, or abnormal distribution of blood (as in distributive shock). While local perfusion might be affected if capillary beds are altered, systemic shock is not triggered simply by a reduction in capillary size. Shock depends on the overall ability of the circulatory system to deliver oxygen to cells, not the anatomical size of capillary networks.

C. Inadequate cardiac output is the hallmark of cardiogenic shock. When the heart cannot pump effectively, perfusion to tissues declines, leading to cellular hypoxia, lactic acidosis, and organ dysfunction. Causes include myocardial infarction, severe heart failure, or arrhythmias that compromise stroke volume.

D. Third spacing occurs when fluid shifts from the intravascular space into interstitial or “third” spaces, as seen in burns, pancreatitis, or severe sepsis. This effectively decreases circulating blood volume, reduces tissue perfusion, and can precipitate hypovolemic-type shock, even though total body fluid may be normal or elevated.