74) A nurse is caring for a client who is in the non-progressive (compensatory) stage ofhypervolemic shock. Which finding should the nurse anticipate? ***(a) Multi-organ Dysfunction Syndrome and seizures(b) Increase thirst reflex and moderate vasoconstriction(c) pH 7.5 and potassium level of 3.0 mEq/L(d) Decrease in MAP by 20 points from baseline
Question
- A nurse is caring for a client who is in the non-progressive (compensatory) stage ofhypervolemic shock. Which finding should the nurse anticipate? ***(a) Multi-organ Dysfunction Syndrome and seizures(b) Increase thirst reflex and moderate vasoconstriction(c) pH 7.5 and potassium level of 3.0 mEq/L(d) Decrease in MAP by 20 points from baseline
Solution 1
The nurse should anticipate an increase in thirst reflex and moderate vasoconstriction (option b).
In the non-progressive (compensatory) stage of hypervolemic shock, the body is trying to compensate for the increased volume of blood. This is done through mechanisms such as vasoconstriction, which helps to maintain blood pressure and perfusion to vital organs. The thirst reflex is also stimulated as the body attempts to increase fluid intake to balance the increased blood volume.
The other options are not typically associated with the compensatory stage of hypervolemic shock. Multi-organ Dysfunction Syndrome and seizures (option a) are more likely to occur in the progressive stage of shock when compensatory mechanisms are failing. A pH of 7.5 and potassium level of 3.0 mEq/L (option c) could indicate a metabolic or respiratory alkalosis, not necessarily hypervolemic shock. A decrease in MAP by 20 points from baseline (option d) would suggest a worsening condition, likely moving into the progressive stage of shock.
Solution 2
The nurse should anticipate an increase in thirst reflex and moderate vasoconstriction (option b).
In the non-progressive (compensatory) stage of hypervolemic shock, the body is trying to compensate for the increased volume of blood. This is done through mechanisms such as vasoconstriction, which helps to maintain blood pressure and perfusion to vital organs. The thirst reflex is also stimulated as the body attempts to increase fluid intake to balance the increased blood volume.
The other options are not typically associated with the compensatory stage of hypervolemic shock. Multi-organ Dysfunction Syndrome and seizures (option a) are more likely to occur in the progressive stage of shock when compensatory mechanisms are failing. A pH of 7.5 and potassium level of 3.0 mEq/L (option c) could indicate a metabolic or electrolyte imbalance, but not specifically hypervolemic shock. A decrease in MAP by 20 points from baseline (option d) would suggest a significant drop in blood pressure, which is more characteristic of the decompensated stage of shock.
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