A client is hospitalized following a road traffic accident (RTA). The nurse obtains the following vital signs: blood pressure (BP) 76/52 mm Hg, heart rate (HR) 124, respiratory rate (RR) 24, and cool clammy skin and rapid breathing. For which life-threatening complication should the nurse carefully monitor the client?

1. A

   Hypovolemic shock

2. B

   Neurogenic shock

3. C

   Septic shock

4. D

   Cardiogenic shock

Appeared in: NORCET 5 mains

Explanation

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• The client's presentation of hypotension (BP 76/52 mm Hg), tachycardia (HR 124), tachypnea (RR 24), and cool, clammy skin after a road traffic accident is the classic picture of hypovolemic shock.
• Hypovolemic shock is the most common type of shock in trauma patients, caused by significant loss of blood and/or fluids.
• The body's compensatory mechanisms for volume loss include increasing the heart rate and constricting peripheral blood vessels, which results in the observed tachycardia and cool, clammy skin.
• The low blood pressure indicates that these compensatory mechanisms are beginning to fail and that there is inadequate tissue perfusion.

Why Other Options Were Wrong

• Option B: Neurogenic shock is characterized by hypotension but is accompanied by bradycardia (a slow heart rate) and warm, dry skin due to widespread vasodilation. The client in the scenario has tachycardia and cool, clammy skin.
• Option C: Septic shock is caused by a systemic infection. While it causes hypotension and tachycardia, the skin is typically warm and flushed in the early stages ('warm shock'). The client's skin is cool and clammy, and the cause is trauma, not infection.
• Option D: Cardiogenic shock results from the heart's inability to pump effectively (pump failure). While it can cause hypotension and cool, clammy skin, the context of a road traffic accident makes massive blood loss far more likely than a sudden cardiac event. There are no signs of cardiac failure (like JVD or pulmonary edema) mentioned.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Recognition and differentiation of shock types based on clinical presentation helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Early recognition of shock is a critical nursing responsibility. Delay in treatment significantly increases mortality.
• In a trauma setting, always assume hypovolemic shock until proven otherwise, and initiate measures for fluid resuscitation immediately upon recognition.
• What if? If the same patient had a BP of 76/52, but the HR was 50 bpm and the skin was warm and dry, the nurse should suspect neurogenic shock, likely from a spinal cord injury sustained in the RTA. The priority would shift to stabilizing the spine and managing the vasodilation.

How to Approach the Question

• First, analyze the clinical scenario: the patient has been in a road traffic accident (RTA), which immediately raises suspicion for trauma and bleeding.
• Next, systematically evaluate the vital signs provided: BP is very low (hypotension), HR is very high (tachycardia), and RR is high (tachypnea).
• Note the physical assessment finding: 'cool clammy skin'. This is a key sign of peripheral vasoconstriction.
• Synthesize the information: Trauma + Hypotension + Tachycardia + Cool Skin.
• Evaluate the options based on this synthesis. Hypovolemic shock is defined by volume loss leading to this exact set of signs.
• Rule out the other options by recalling their key differentiating features: Neurogenic (bradycardia, warm skin), Septic (infection, warm skin initially), Cardiogenic (pump failure, not trauma-induced volume loss).

Concept Tested & Keywords

• Concept Tested: Recognition and differentiation of shock types based on clinical presentation.
• Stem keywords: road traffic accident (RTA), blood pressure (BP) 76/52 mm Hg, heart rate (HR) 124, respiratory rate (RR) 24, cool clammy skin
• Lead-in keywords: life-threatening complication
• Clinical cues: The combination of trauma (RTA) with hypotension, tachycardia, and cool skin strongly points towards volume loss.

Question ID

QNYWGmv1W3lUpYmHgw8J5z

Copy ID

Reference Book

E6 Nursing Vital Signs pp. 88-90, 87-89

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 113-115