A nurse, assessing a client hospitalized following a road traffic accident (RTA), obtains the following vital signs: blood pressure (BP) 80/55 mm Hg, heart rate (HR) 128, 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 -4 , 2023

Explanation

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• The client's presentation of hypotension (BP 80/55 mm Hg), tachycardia (HR 128), and cool, clammy skin after a road traffic accident points directly to hypovolemic shock.
• This type of shock is caused by a significant loss of circulating blood volume, most commonly from hemorrhage in trauma patients.
• The body's compensatory mechanisms include increasing the heart rate to circulate the remaining blood faster and constricting peripheral blood vessels (causing cool, clammy skin) to divert blood to vital organs.
• The rapid respiratory rate is the body's attempt to compensate for the decreased oxygen-carrying capacity due to blood loss.

Why Other Options Were Wrong

• Option B: Neurogenic shock is characterized by hypotension but with bradycardia (a slow heart rate), not tachycardia. The skin is typically warm and dry due to widespread vasodilation from loss of sympathetic tone.
• Option C: Septic shock is caused by a systemic infection. While it causes hypotension and tachycardia, it is typically associated with fever and, in its early stages, warm, flushed skin ('warm shock'), not the cool, clammy skin seen in this client.
• Option D: Cardiogenic shock results from the heart's failure to pump effectively. While it presents with hypotension and tachycardia, it is a pump problem, not a volume problem. It is often accompanied by signs of fluid overload like jugular venous distention (JVD) and pulmonary edema (crackles in the lungs), which are not indicated here.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Recognition and differentiation of types of shock based on clinical presentation helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Prompt recognition of hypovolemic shock is a critical nursing skill, as it is a life-threatening emergency requiring immediate intervention to prevent organ failure and death.
• The primary nursing goals are to restore circulating volume with IV fluids and/or blood products, support oxygenation, and continuously monitor the patient's response to treatment.
• What if? If the same patient had a BP of 80/55 mm Hg but a heart rate of 52 bpm and warm, dry skin, the nurse should suspect neurogenic shock, likely from a spinal cord injury, and the priority interventions would shift to include vasopressors and management of potential spinal immobilization.

How to Approach the Question

• First, analyze the context: The patient has been in a road traffic accident (RTA), which has a high risk of trauma and bleeding.
• Next, systematically evaluate the vital signs and clinical findings provided: BP is low, HR is high, RR is high, and skin is cool and clammy.
• Consider the pathophysiology of each option. How does each type of shock affect these specific vital signs?
• Correlate the patient's signs with the expected presentation of each shock type. The combination of low volume (trauma), low BP, high HR, and peripheral vasoconstriction (cool skin) is the classic picture of hypovolemic shock.
• Eliminate the other options based on their classic presentations: Neurogenic (bradycardia, warm skin), Septic (fever, warm skin initially), and Cardiogenic (pump failure signs like JVD).

Concept Tested & Keywords

• Concept Tested: Recognition and differentiation of types of shock based on clinical presentation.
• Stem keywords: road traffic accident (RTA), vital signs, blood pressure 80/55 mm Hg, heart rate 128, respiratory rate 24, cool clammy skin
• Lead-in keywords: life-threatening complication, monitor
• Clinical cues: The combination of trauma (RTA), hypotension, and tachycardia is a strong indicator of significant volume loss.

Question ID

QgWbCe7ajeJbgX61AyQ9sh

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