Question

When the nurse observes that the patient's systolic blood pressure is less than 80 to 90 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc per hour, the nurse recognizes that the patient is demonstrating which stage of shock?

a) Irreversible
b) Refractory
c) Progressive
d) Compensatory

Answer 1

The patient is demonstrating the compensatory stage of shock. During this stage, the body activates compensatory mechanisms to maintain blood flow to vital organs.

Step-by-step explanation:

The patient is demonstrating compensatory stage of shock. The compensatory stage is the initial stage of shock where the body tries to maintain blood flow to vital organs by activating compensatory mechanisms. In this stage, the patient may exhibit an increased heart rate (>150 beats per minute), rapid and shallow respirations, and decreased urine output (<30 cc per hour). The systolic blood pressure may be less than 80-90 mm Hg.

During the compensatory stage, the body releases stress hormones like epinephrine and norepinephrine, which constrict blood vessels and increase heart rate to improve blood flow. The body also tries to conserve fluids by reducing urine output. However, if the underlying cause of shock is not resolved, the compensatory mechanisms may eventually fail and progress to the progressive and irreversible stages.