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 B
Explanation
Choice A rationale
Progressive increase in platelet production is not a characteristic of DIC. DIC typically involves a decrease in platelet count due to consumption.
Choice B rationale
Excessive thrombosis and bleeding are hallmark features of DIC, as the condition involves both clot formation and bleeding due to the consumption of clotting factors.
Choice C rationale
Immediate sodium and fluid retention are not characteristic findings of DIC.
Choice D rationale
Increased clotting factors are not seen in DIC; instead, there is a consumption of clotting factors leading to their decrease.
Correct Answer is C
Explanation
Choice A rationale
Decreased temperature is not typically an immediate complication following a thoracentesis. It may indicate an infection, but this would develop over time rather than immediately after the procedure.
Choice B rationale
Serosanguineous drainage from the puncture site is expected after a thoracentesis and does not indicate a complication that requires immediate attention.
Choice C rationale
Shortness of breath is a serious complication that can indicate a pneumothorax or re- accumulation of fluid in the pleural space. This requires immediate attention and intervention by the healthcare provider.
Choice D rationale
Chest pain can be a sign of a complication such as a pneumothorax or infection. However, shortness of breath is a more immediate and severe symptom that requires urgent attention.