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 D
Explanation
Choice A rationale
Hypokalemia can cause muscle weakness and cramps, but it does not typically lead to severe muscle spasms causing exhaustion. The patient’s symptoms of lethargy and weakness are more likely related to electrolyte imbalances and dehydration rather than muscle spasms.
Choice B rationale
While low potassium levels can affect cellular metabolism, the primary issue here is not glycolysis. The patient’s symptoms are more consistent with dehydration and electrolyte imbalances rather than a metabolic shift to glycolysis.
Choice C rationale
Hypokalemia can cause cells to become hyperpolarized, leading to muscle weakness and decreased reflexes. However, the patient’s symptoms of lethargy and weakness are more likely due to dehydration and electrolyte imbalances rather than cellular hyperpolarization.
Choice D rationale
Hypernatremia, or high sodium levels, can cause cellular dehydration, leading to symptoms such as lethargy and weakness. The patient’s lab results and clinical presentation are consistent with hypernatremia-induced cellular dehydration, which explains his symptoms.
Correct Answer is A
Explanation
Choice A rationale
Decreasing coronary artery constriction by giving aspirin is a primary objective in managing unstable angina. Aspirin inhibits platelet aggregation, reducing the risk of clot formation and improving blood flow in the coronary arteries. This helps to alleviate chest pain and prevent myocardial infarction.
Choice B rationale
Increasing afterload for the left ventricle to maximize cardiac output is not a desirable objective in managing unstable angina. Increasing afterload would increase the workload on the heart, which is counterproductive in patients with angina. The goal is to reduce the heart’s workload and improve blood flow.
Choice C rationale
Increasing preload to reduce overall cardiac workload is not a primary objective in managing unstable angina. Increasing preload would increase the volume of blood returning to the heart, potentially worsening symptoms. The focus is on reducing myocardial oxygen demand and improving coronary perfusion.
Choice D rationale
Reducing arterial inflammation by administering statins is a long-term strategy for managing cardiovascular disease, but it is not the immediate objective in managing unstable angina. Statins help to lower cholesterol levels and reduce inflammation, but the immediate goal in unstable angina is to relieve chest pain and prevent myocardial infarction.