A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours.
Which of the following categories of shock should the nurse recognize is occurring?
Hypovolemic shock.
Septic shock.
Neurogenic shock.
Obstructive shock.
The Correct Answer is C
Choice A rationale
Hypovolemic shock occurs due to a significant decrease in circulating blood volume, leading to inadequate tissue perfusion. Blood loss, such as the 800 mL lost during surgery, is a common cause of hypovolemic shock. The steadily decreasing blood pressure is consistent with this type of shock.
Choice B rationale
Septic shock results from a systemic inflammatory response to infection, leading to vasodilation and maldistribution of blood flow. There is no indication of infection in this scenario.
Choice C rationale
Neurogenic shock results from a loss of sympathetic tone, leading to vasodilation and relative hypovolemia. It is often associated with spinal cord or severe head injury, which is not indicated in this scenario.
Choice D rationale
Obstructive shock occurs when there is an obstruction to blood flow within the cardiovascular system, such as a pulmonary embolism or cardiac tamponade. There is no evidence of such an obstruction in this scenario.
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Correct Answer is C
Explanation
Choice A rationale
Hypercyanotic spells, also known as “tet spells,” are typically associated with Tetralogy of Fallot, a congenital heart defect. The child in this scenario has congenital mitral stenosis, not Tetralogy of Fallot, making hypercyanotic spells less likely.
Choice B rationale
A murmur is a sound made by turbulent blood flow within the heart. While the child may have a murmur due to congenital mitral stenosis, it is not a direct risk associated with the exacerbation of heart failure. The primary concern here is the risk of digitalis toxicity due to the administration of furosemide.
Choice C rationale
Digitalis toxicity is a significant risk for this child. Furosemide, a diuretic, can cause electrolyte imbalances, particularly hypokalemia, which increases the risk of digitalis toxicity. Symptoms of digitalis toxicity include nausea, vomiting, dizziness, and arrhythmias.
Choice D rationale
Dependent rubor is a reddish-blue discoloration of the extremities, typically associated with peripheral arterial disease. It is not directly related to heart failure or the administration of furosemide.
Choice E rationale
Fever is not a typical complication of heart failure or the administration of furosemide. It is more commonly associated with infections or inflammatory conditions.
Choice F rationale
Carditis, or inflammation of the heart, is not a direct risk associated with the exacerbation of heart failure or the administration of furosemide. The primary concern remains digitalis toxicity.
Correct Answer is A
Explanation
Choice A rationale
Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle. This is correct because atherosclerosis, which is the buildup of plaque in the coronary arteries, causes the arteries to narrow. This narrowing reduces blood flow to the heart muscle, leading to ischemia and the manifestations of coronary artery disease, such as angina and myocardial infarction.
Choice B rationale
Manifestations occur due to dilation of coronary arteries with increased blood flow causing increased pressure. This is incorrect because the primary issue in coronary artery disease is the narrowing of the arteries, not their dilation. Increased blood flow and pressure are not typical causes of the manifestations of coronary artery disease.
Choice C rationale
Coronary arteries become more elastic causing the arteries to stretch as individuals age causing the heart not to receive enough oxygen. This is incorrect because the problem in coronary artery disease is not increased elasticity but rather the loss of elasticity and the buildup of plaque that narrows the arteries. As people age, the arteries tend to become less elastic, not more.
Choice D rationale
The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina. This is incorrect because the primary issue in coronary artery disease is the narrowing of the coronary arteries due to plaque buildup, not the weakening of the heart and arteries. While poor perfusion does result in angina, it is due to the narrowed arteries rather than weakened structures.