Question

The nurse is assessing a client with irreversible shock. The nurse should document the progression of which expected finding?

1. increased alertness
2. circulatory collapse
3. hypertension
4. diuresis

Answer 1

A nurse should document circulatory collapse as the expected finding in a patient with irreversible shock, indicated by symptoms like dramatic decreases in urine output, confusion, and altered levels of consciousness accompanied by hypotension.

Step-by-step explanation:

The nurse assessing a client with irreversible shock should document the progression of circulatory collapse. Irreversible shock is a critical condition where the circulatory system fails to maintain blood flow and oxygen delivery to the tissues, leading to cellular metabolism disruption. This progression includes symptoms such as a dramatic fall in urine output, confusion, loss of consciousness, and a potential hypotensive state with a rapid, weak pulse, cool and clammy skin, and shallow breathing. The hypotension and altered mental state indicate the severity of the shock. Accordingly, option 2, circulatory collapse, is the expected finding to document in a patient with irreversible shock.