64. A client's vital signs are: BP 80/60 mm Hg, P 120, R 30, T 100.4°F. A nurse should know that these findings most likely indicate:
64. A client's vital signs are: BP 80/60 mm Hg, P 120, R 30, T 100.4°F. A nurse should know that these findings most likely indicate:
. Neurogenic shock from increased intracranial pressure.
. Hypovolemic shock from fluid volume deficits.
. Septic shock from gram-negative sepsis.
. Cardiogenic shock from MI.
Test-Taking Tip
Each type of shock has a unique characteristic. Know the clinical indications.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is incorrect because the overriding parasympathetic stimulation causes bradycardia, not tachycardia (pulse = 120 here). Answer 2 is correct because the hypotension and tachycardia are classic signs of hypovolemic shock. Answer 3 is incorrect because the temperature would be higher in septic shock, usually greater than 38°C. Answer 4 is incorrect because in cardiogenic shock the pulse would not be increased because the contractility of the heart is ineffective.