A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
Explanation & Rationale
A. Blood pressure 84/50 mm Hg: A blood pressure of 84/50 mm Hg is indicative of hypotension, which may be seen in the progressive or decompensatory stage of shock, not in the compensatory stage, where the body usually maintains blood pressure through compensatory mechanisms. B. Anuria: Anuria, or the complete absence of urine output, suggests renal failure and is typically seen in the progressive or decompensatory stages of shock when organ perfusion is severely compromised, rather than in the compensatory stage. C. Petechiae: Petechiae (small, pinpoint hemorrhages) suggest clotting abnormalities or disseminated intravascular coagulation (DIC), which can occur in severe shock but is not typical in the compensatory stage. D. Confusion: Confusion can occur in the compensatory stage of shock as the body struggles to maintain adequate perfusion to vital organs, particularly the brain. Confusion is often the earliest sign of a decrease in cerebral perfusion and can be expected in this stage of shock.