A nurse is assessing a client who presents with a temperature of 38°C (100.4°F), a heart rate of 110 beats per minute, and a blood pressure of 90/60 mmHg. Which condition is the client most likely experiencing?
Septic shock.
Hypovolemic shock.
Cardiogenic shock.
Neurogenic shock.
The Correct Answer is A
Choice A rationale
Septic shock is characterized by a systemic inflammatory response to infection, leading to vasodilation, increased capillary permeability, and hypotension. The patient’s elevated temperature, tachycardia, and hypotension are consistent with septic shock. In septic shock, the body’s response to infection leads to widespread inflammation and impaired tissue perfusion.
Choice B rationale
Hypovolemic shock is caused by a significant loss of blood or fluids, leading to decreased circulating volume and hypotension. While the patient’s hypotension and tachycardia could be consistent with hypovolemic shock, the elevated temperature suggests an infectious process, making septic shock more likely.
Choice C rationale
Cardiogenic shock is caused by the heart’s inability to pump effectively, leading to decreased cardiac output and tissue perfusion. While hypotension and tachycardia are consistent with cardiogenic shock, the elevated temperature is not a typical finding. Cardiogenic shock is usually associated with conditions like myocardial infarction or severe heart failure.
Choice D rationale
Neurogenic shock is caused by a disruption in the autonomic pathways, leading to vasodilation and hypotension. It is typically associated with spinal cord injuries or severe head trauma. The patient’s elevated temperature and tachycardia are not consistent with neurogenic shock, making septic shock the more likely diagnosis.
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Correct Answer is A
Explanation
Choice A rationale
A positive Brudzinski’s sign is indicative of meningitis. It involves involuntary lifting of the legs when the neck is flexed, suggesting meningeal irritation.
Choice B rationale
A positive Babinski’s sign indicates central nervous system pathology but is not specific to meningitis. It involves dorsiflexion of the big toe when the sole of the foot is stimulated.
Choice C rationale
A positive Romberg’s sign indicates issues with proprioception and balance but is not specific to meningitis. It involves swaying or falling when standing with eyes closed.
Choice D rationale
A positive Murphy’s sign indicates gallbladder inflammation (cholecystitis) and is not related to meningitis. It involves pain on palpation of the right upper quadrant during inspiration.
Correct Answer is B
Explanation
Choice A rationale
Deep vein thrombosis (DVT) can lead to pulmonary embolism but does not directly cause chest pain and shortness of breath.
Choice B rationale
Pulmonary embolus (PE) is characterized by chest pain, shortness of breath, and hemoptysis (coughing up blood), especially in patients on bed rest.
Choice C rationale
Anemia can cause fatigue and shortness of breath but not typically chest pain and hemoptysis.
Choice D rationale
Right heart failure can cause shortness of breath and edema but not typically chest pain and hemoptysis.