NCLEX-RN

Answer: C - Hypotension and increase in heart rate indicate hypovolemic shock. It is the body’s homeostatic response to a sudden loss of fluid volume. The assessment gives no indication of blood loss or type of injuries. However, fluid volume deficit is the priority nursing diagnosis for a client involved in a motor vehicle accident experiencing a decrease in blood pressure and increasing heart rate. Hypovolemic shock can quickly develop into a life-threatening event if left untreated. The priority nursing diagnosis is fluid volume deficit with appropriate priority nursing interventions.