A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

Choice A rationale While low blood pressure is a hallmark of the late stages of hypovolemic shock, a low pulse rate is physiologically inconsistent with the body's compensatory mechanisms. When blood volume drops, the baroreceptors sense a decrease in stretch and trigger the sympathetic nervous system. This normally results in an increased heart rate to maintain cardiac output. A low pulse rate in the presence of hypotension usually suggests a neurogenic cause or a failed compensatory state. Choice B rationale High blood pressure is not expected in hypovolemic shock because the primary problem is a decrease in intravascular volume. With less fluid to exert pressure against arterial walls, the systolic pressure eventually falls. While early compensation might maintain a normal blood pressure through vasoconstriction, it will not become "high.”. A low pulse rate is also the opposite of the expected tachycardic response used to compensate for a reduced stroke volume in shock. Choice C rationale A high pulse rate is a correct compensatory finding, but high blood pressure is incorrect for hypovolemia. In the initial stages of shock, the body releases catecholamines which cause vasoconstriction, potentially keeping the blood pressure within a normal range (90 to 120 mmHg systolic). However, as volume loss continues, the blood pressure will inevitably drop. High blood pressure typically indicates fluid overload or systemic hypertension, which are the physiological opposites of a hypovolemic state. Choice D rationale Low blood pressure and a high pulse rate are classic signs of hypovolemic shock. As circulating volume decreases, mean arterial pressure drops. The body compensates via the sinoatrial node increasing the heart rate (tachycardia, usually greater than 100 beats per minute) to maintain oxygen delivery to tissues. Normal systolic blood pressure is 90 to 120 mmHg; values below this, combined with a rapid heart rate, signify that the body is struggling to maintain systemic perfusion.