Question

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding ___.

a. cold, mottled extremities.
b. restlessness and apprehension.
c. a heart rate of 120 and cool, clammy skin.
d. systolic BP less than 90 mm Hg.

Answer 1

In the compensatory stage of shock, the patient may exhibit restlessness and apprehension, as the body is actively attempting to maintain adequate blood flow and organ function.

Step-by-step explanation:

While caring for a seriously ill patient who may be in the compensatory stage of shock, the nurse can determine this based on the presence of restlessness and apprehension. This symptom aligns with the body's initial response to maintain organ function in the face of decreasing circulatory efficiency. Other signs that may accompany this stage are an increased heart rate, normal or slightly decreased blood pressure, and a slight change in mental status, indicating that the body is trying to compensate for the impaired circulatory condition.

Options such as cold, mottled extremities and a systolic BP less than 90 mm Hg, while also associated with shock, might suggest more advanced stages beyond initial compensation. A heart rate of 120 with cool, clammy skin also signifies a response to shock, but the presence of restlessness and apprehension specifically corresponds with a body that is not yet in severe shock and is still compensating for circulatory deficits.