1) The nurse is concerned that a client is demonstrating early signs of hypovolemic shock. What
did the nurse assess in this client?
Select all that apply.
A) Slight increase in pulse
B) Prolonged capillary refill time
C) Rapid weak pulse
D) Normal respirations
E) Normal blood pressure
Answer: A, B, D, E
Explanation: A) Manifestations of early hypovolemic shock include a slight increase in pulse,
normal respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid
pulse is a characteristic of the irreversible stage of hypovolemic shock.
B) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
C) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
D) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
E) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
Page Ref: 1224
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct
and indirect causes of shock.
, 2) A young client with a history of multiple allergies is prescribed epinephrine (EpiPen) for
prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was
about heart failure." What is the best response by the nurse?
A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart
failure, and liver failure."
B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and
loss of blood."
C) "There are many kinds of shock that also include infection, nervous system damage, and loss
of blood."
D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and
respiratory failure."
Answer: C
Explanation: A) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal
cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent
infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms
may suggest anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not
a type of shock. Liver failure is not a type of shock.
B) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of
shock. Liver failure is not a type of shock.
C) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of
shock. Liver failure is not a type of shock.
D) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of
shock. Liver failure is not a type of shock.
Page Ref: 1222-1224
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with shock.
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