NCLEX Question for stage of shock

NCLEX Review Question

When the nurse observes that the patient's systolic blood pressure is less than 80--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.Compensatory
b.Progressive
c.Refractory
d.Irreversible

Correct Answer: A
Compensatory
Rationale: In compensatory shock, the patient's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150.

Progressive
Rationale: In progressive shock, the patient's skin appears mottled and mentation demonstrates lethargy.

Refractory
Rationale: In refractory or irreversible shock, the patient requires complete mechanical and pharmacologic support.

Irreversible
Rationale: In refractory or irreversible shock, the patient requires complete mechanical and pharmacologic support.

Posted in: MSN NCLEX