A nurse and a newly licensed nurse are providing care for a client who has distributive shock. How should the nurse explain the pathophysiology of distributive shock to the newly licensed nurse?
"Distributive shock occurs due to increased systemic vascular resistance."
"Distributive shock occurs due to systemic vasodilation."
"Distributive shock occurs due to loss of myocardial contractility."
"Distributive shock occurs due to loss of blood volume."
The Correct Answer is B
A. Increased systemic vascular resistance is typically associated with hypovolemic or cardiogenic shock, not distributive shock.
B. Distributive shock is characterized by systemic vasodilation, which leads to a decrease in systemic vascular resistance and results in inadequate tissue perfusion despite normal or increased cardiac output.
C. Loss of myocardial contractility is related to cardiogenic shock, not distributive shock.
D. Loss of blood volume is a characteristic of hypovolemic shock, whereas distributive shock occurs even when blood volume is normal due to vasodilation.
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Correct Answer is D
Explanation
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.
Correct Answer is C
Explanation
A. DIC is characterized by a low platelet count due to the consumption of platelets in the coagulation process, not an elevated count.
B. While heparin may be used in the management of DIC in some cases, it is not a lifelong treatment nor a cure for the condition, as DIC results from an underlying condition rather than being a standalone disease.
C. DIC involves the overactivation of the coagulation cascade, leading to the formation of fibrin clots and subsequent consumption of clotting factors and platelets, thus making this statement accurate.
D. DIC is not a genetic disorder but rather a complication often associated with severe infections, trauma, or other conditions, and it is not primarily due to vitamin K deficiency.