NCLEX-RN

Category - Physiological

A nurse is caring for a client presenting with cold extremities, hypoactive bowel sounds and decreased urine output. The client is in the compensatory stage of shock, which is characterized by:
  1. Mean arterial pressure (MAP) falling below normal range - progressive
  2. Stimulation of the sympathetic nervous system (SNS) and release of catecholamines - compensatory
  3. Increased capillary permeability leading to massive vasoconstriction - progressive
  4. Multi-organ malfunction - irreversible
Explanation
Answer: B - The compensatory stage of shock is characterized by stimulation of the SNS and release of catecholamines to prevent collapse of the circulatory system. When the MAP falls below normal range or massive vasoconstriction occurs, the progressive stage of shock has begun. In this stage, cellular perfusion is compromised. The last and irreversible stage occurs when organ damage is so severe that the body cannot respond to treatment, and death will eventually occur.
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