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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Breast cancer can occur in any part of the breast, but ductal breast cancer is most common. This statement is correct because the majority of breast cancers originate in the ducts that carry milk to the nipple. Ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) are the most common types of breast cancer, accounting for about 80% of all cases.
Choice B rationale
Breastfeeding increases the risk of breast cancer in women over 40 years of age. This statement is incorrect. In fact, breastfeeding is known to reduce the risk of breast cancer. The longer a woman breastfeeds, the greater the protective effect. This is thought to be due to hormonal changes that occur during lactation, which may delay the return of menstrual periods and reduce a woman’s lifetime exposure to hormones like estrogen that can promote breast cancer cell growth.
Choice C rationale
Clients who have BRCA1 or BRCA2 gene changes have a decreased risk of breast cancer. This statement is incorrect. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer. Women with these mutations have a 45-65% chance of developing breast cancer by age 70, compared to about 12% for women in the general population. These genes normally help repair DNA damage, but when they are mutated, they can lead to the development of cancer.
Choice D rationale
Clients should begin screening mammography annually by the age of 50 years old. This statement is partially correct but not entirely accurate. The American Cancer Society recommends that women with an average risk of breast cancer should start annual mammograms at age 45 and can switch to biennial screening at age 55. However, women should have the option to start screening as early as age 40 if they choose.
Correct Answer is D
Explanation
Choice A rationale
Constant bubbling in the suction-control chamber is expected and indicates that the suction is functioning properly.
Choice B rationale
Bloody drainage in the collection chamber is expected in the immediate postoperative period and does not require intervention.
Choice C rationale
Fluid-level fluctuations in the water-seal chamber are normal and indicate that the system is functioning properly.
Choice D rationale
Continuous bubbling in the water-seal chamber indicates an air leak and requires intervention to prevent complications.
