Which stage of shock is characterized by decreased blood pressure and inadequate tissue perfusion?
Irreversible stage
Refractory stage
Progressive stage
Compensatory stage
The Correct Answer is C
Choice A Reason:
The irreversible stage of shock, also known as the terminal stage, is characterized by severe organ damage and failure. At this point, the body's compensatory mechanisms have failed, and recovery is unlikely. Decreased blood pressure and inadequate tissue perfusion are present, but they are more pronounced in the progressive stage.
Choice B Reason:
The refractory stage is often used interchangeably with the irreversible stage. It signifies a point where shock has progressed to such an extent that treatment is no longer effective. The body's organs have sustained irreversible damage, and despite medical intervention, the patient is unlikely to survive.
Choice C Reason:
The progressive stage of shock is characterized by a significant drop in blood pressure and inadequate tissue perfusion. During this stage, the body's compensatory mechanisms begin to fail, leading to worsening hypoperfusion and cellular damage. This stage is critical as it marks the transition from reversible to potentially irreversible damage if not promptly treated.
Choice D Reason:
The compensatory stage, also known as the non-progressive stage, involves the body's initial response to shock. During this stage, mechanisms such as increased heart rate and vasoconstriction work to maintain blood pressure and perfusion to vital organs. Blood pressure may still be within normal limits, and tissue perfusion is maintained, albeit at a reduced level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Consuming a diet high in vitamin K to promote clotting is not typically recommended for patients with DIC. While vitamin K is essential for clotting, DIC involves both excessive clotting and bleeding. Increasing vitamin K intake could exacerbate clotting issues without addressing the underlying imbalance.
Choice B Reason:
Stopping all medications to prevent interactions with clotting factors is not advisable. Patients with DIC often require medications to manage their condition, including anticoagulants and treatments for the underlying cause. Discontinuing all medications could lead to uncontrolled symptoms and complications.
Choice C Reason:
Engaging in physical activity to promote blood flow is generally beneficial for overall health, but in the context of DIC, it must be approached with caution. Physical activity can increase the risk of injury and bleeding, which is a significant concern for patients with DIC. Therefore, any exercise regimen should be carefully monitored and tailored to the patient's condition.
Choice D Reason:
Avoiding activities that may cause injury or bleeding is crucial for patients with DIC. Due to the risk of spontaneous bleeding and the potential for minor injuries to lead to significant blood loss, patients must take precautions to minimize these risks. This includes avoiding contact sports, using soft-bristled toothbrushes, and being cautious with sharp objects.
Correct Answer is C
Explanation
Choice A Reason:
Allowing the client to control the timing and frequency of the therapy might seem beneficial, but it can lead to inconsistent participation and lack of progress. Structured therapy sessions are essential for rehabilitation, and while some flexibility is important, a completely client-controlled schedule may not provide the necessary consistency.
Choice B Reason:
Limiting visiting hours until the client begins to participate in therapy is not an effective approach. Social support from family and friends is crucial for the emotional well-being of the client and can actually motivate them to engage more in their rehabilitation efforts. Restricting visits could lead to increased feelings of isolation and resistance.
Choice C Reason:
Establishing a plan of care with the client that sets attainable goals is the most effective approach. Involving the client in their care plan fosters a sense of ownership and motivation. Setting realistic and achievable goals helps the client see progress, which can boost their confidence and willingness to participate in therapy.
Choice D Reason:
Informing the client that privileges are related to participation in therapy can be perceived as punitive and may not be effective in motivating the client. It is important to use positive reinforcement and encouragement rather than threats or restrictions to foster cooperation and engagement in the rehabilitation process.
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