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 D
Explanation
Choice A rationale
While chest pain can occur after pacemaker insertion, it is not the primary concern immediately following the procedure. The nurse should monitor for more critical complications such as arrhythmias, which can indicate pacemaker malfunction or lead displacement.
Choice B rationale
Infection is a potential complication after pacemaker insertion, but it typically develops over a longer period. Immediate monitoring should focus on acute complications such as arrhythmias.
Choice C rationale
Bleeding is a concern after any surgical procedure, including pacemaker insertion. However, the primary immediate concern is monitoring for arrhythmias, which can indicate issues with the pacemaker’s function.
Choice D rationale
Arrhythmias are the primary concern immediately following pacemaker insertion. The nurse should monitor the client for any irregular heart rhythms, which can indicate pacemaker malfunction or lead displacement. Prompt identification and management of arrhythmias are crucial to ensure the pacemaker is functioning correctly.
Correct Answer is B
Explanation
Choice A rationale
An abdominal aortic aneurysm (AAA) is most commonly found infrarenally, below the level of the renal arteries, rather than in the suprarenal aorta. The suprarenal aorta is the section of the aorta above the renal arteries, and while aneurysms can occur there, it is not the most common location for AAAs. Therefore, this statement is incorrect.
Choice B rationale
An abdominal aortic aneurysm is defined as a localized dilation of the abdominal aorta that exceeds 50% of the normal vessel diameter, typically greater than 30 mm in diameter. This dilation occurs due to weakening of the arterial wall, which can result from various factors such as atherosclerosis, hypertension, and genetic predisposition. This statement is correct and should be included in the teaching.
Choice C rationale
An abdominal aortic aneurysm typically occurs due to weakening of the arterial wall, rather than thickening. The weakened wall allows the arterial wall to bulge or balloon out, forming an aneurysm. This statement is incorrect as it misrepresents the pathophysiology of AAAs.
Choice D rationale
Abdominal aortic aneurysms are more likely to rupture when blood pressure is too high, rather than too low. Hypertension increases the pressure within the weakened arterial wall, potentially leading to rupture. Therefore, controlling blood pressure is crucial in managing abdominal aortic aneurysms to reduce the risk of rupture. This statement is incorrect.