Difficulty: Medium
Average Score: 70%
Simulated
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Correct answer
C
Rationale
Correct Answer: C - Blood pressure 115/68 mmHg
Rationale:
1. In the compensatory stage of shock, the body attempts to maintain blood pressure by vasoconstriction.
2. A blood pressure of 115/68 mmHg indicates the body's compensatory efforts to maintain perfusion.
3. Mottled skin (A) is a sign of decreased perfusion, not expected in the compensatory stage.
4. A heart rate of 160/min (B) is more likely to be seen in the progressive stage of shock.
5. Hypokalemia (D) is not a typical finding in the compensatory stage of shock.
Summary:
- Mottled skin (A) and heart rate of 160/min (B) are signs of worsening shock.
- Hypokalemia (D) is not directly related to the compensatory stage of shock.
Rationale:
1. In the compensatory stage of shock, the body attempts to maintain blood pressure by vasoconstriction.
2. A blood pressure of 115/68 mmHg indicates the body's compensatory efforts to maintain perfusion.
3. Mottled skin (A) is a sign of decreased perfusion, not expected in the compensatory stage.
4. A heart rate of 160/min (B) is more likely to be seen in the progressive stage of shock.
5. Hypokalemia (D) is not a typical finding in the compensatory stage of shock.
Summary:
- Mottled skin (A) and heart rate of 160/min (B) are signs of worsening shock.
- Hypokalemia (D) is not directly related to the compensatory stage of shock.