Question

A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the irreversible stage of shock when what is included in assessment findings?

a. A lactic acidosis with a pH of 7.32
b. Marked hypotension and refractory hypoxemia
c. Unresponsiveness that responds only to painful stimuli
d. Profound vasoconstriction with absent peripheral pulses

Answer 1

The nurse recognizes that the patient is in the irreversible stage of shock when profound vasoconstriction with absent peripheral pulses is included in assessment findings. This indicates severe tissue hypoperfusion and can lead to organ failure and death.

Step-by-step explanation:

The nurse recognizes that the patient is in the irreversible stage of shock when profound vasoconstriction with absent peripheral pulses is included in assessment findings. In this stage, the body's compensatory mechanisms are overwhelmed, and the patient's condition becomes refractory to treatment. The profound vasoconstriction and absent peripheral pulses indicate severe tissue hypoperfusion, which can lead to organ failure and death.