Nokea
Which compensatory mechanism, during the first stage of shock, does the nurse identify as responsible for stabilization of fluid balance?
- A. Catecholamines
- B. Corticosteroid hormones
- C. Renin-angiotensin
- D. Aldosterone
Correct Answer: B
Rationale: Corticosteroids, including mineral corticoids such as aldosterone, conserve sodium and promote potassium excretion. This plays an active role in controlling sodium and water balance. Catecholamines impact the sympathetic nervous system. The renin-angiotensin-aldosterone system impacts blood volume.
You may also like to solve these questions
The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?
- A. Obstructive
- B. Hypovolemic
- C. Carcinogenic
- D. Distributive
Correct Answer: D
Rationale: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such condition as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
- A. Place a cool compress on head.
- B. Elevate the legs higher than the heart.
- C. Shake the client to arouse.
- D. Cover the client with a blanket.
Correct Answer: B
Rationale: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.
The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
- A. A rise in blood count
- B. Alertness in level of consciousness
- C. Increased heart rate
- D. Pulse oxygenation level of $92 \%$
Correct Answer: B
Rationale: In hypovolemic shock, the volume of extracellular fluid is significantly diminished because of lost or reduced blood or plasma. Circulation is impaired. Alertness in the level of consciousness indicates improved circulation and thus oxygenation to the brain. A documented rise in blood count is promising unless tissue damage has already occurred. A decrease in heart rate would mean the heart is no longer struggling to circulate blood to meet tissue needs. A pulse oxygenation level of $92 \%$ is a good sign of available oxygen for the tissue.
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
- A. A rapid, bounding pulse
- B. A slow but steady pulse
- C. A weak and thready pulse
- D. A slow and imperceptible pulse
Correct Answer: A
Rationale: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
- A. Blanch the nailbeds.
- B. Inspect the conjunctiva.
- C. Note dullness in skin color.
- D. Assess the earlobe.
Correct Answer: B
Rationale: In clients with highly pigmented skin, cyanosis is more accurately detected by inspecting the conjunctiva and oral mucous membranes. The other options do not provide the best assessment for cyanosis.