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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A rationale
It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. This is why the patient is asked to return in 2 to 3 weeks for an antibody titer. The immune system needs time to respond to the vaccine and produce detectable levels of antibodies.
Choice B rationale
The laboratory running out of blood specimen tubes is not a valid reason for delaying the antibody titer. This choice does not provide an accurate explanation for the patient.
Choice C rationale
It takes about 14 days to develop antibodies, not antigens, and immunity to the disease after vaccine administration. This choice contains incorrect information about the immune response.
Choice D rationale
After receiving the vaccine, the patient is not likely to transmit the communicable disease to the laboratory. This choice does not provide a valid reason for delaying the antibody titer.
Correct Answer is A
Explanation
Choice A rationale
A blood pressure reading of 180/120 mmHg or higher is indicative of a hypertensive crisis. This condition requires immediate medical attention to prevent damage to vital organs such as the heart, kidneys, and brain.
Choice B rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate a hypertensive crisis. While it is important to monitor heart rate, it is not a definitive sign of a hypertensive emergency.
Choice C rationale
A respiratory rate of 20 breaths per minute is within the normal range and does not indicate a hypertensive crisis. Respiratory rate alone is not a reliable indicator of hypertensive emergencies.
Choice D rationale
A temperature of 37°C (98.6°F) is normal and does not indicate a hypertensive crisis. Body temperature is not a primary indicator of hypertensive emergencies.