A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
A.
Hypertension
B.
Bradypnea
C.
Oliguria
D.
Flushing of the skin
The Correct Answer and Explanation is:
The correct answer is:
C. Oliguria
Explanation:
Hypovolemic shock occurs when there is a significant loss of blood or fluid, leading to inadequate circulating volume and reduced perfusion to tissues and organs. This condition can be caused by trauma, severe dehydration, burns, or hemorrhage. The body responds to hypovolemic shock by activating compensatory mechanisms to maintain blood pressure and ensure perfusion to vital organs.
Key Clinical Manifestations of Hypovolemic Shock:
- Hypotension: As the circulating volume decreases, blood pressure drops, leading to hypotension. This occurs because there is less blood available to circulate through the body, reducing the pressure within the arteries.
- Tachypnea: In response to decreased oxygen delivery, the respiratory rate increases (tachypnea) as the body attempts to improve oxygenation and eliminate carbon dioxide.
- Oliguria: Oliguria, or decreased urine output, is a common and expected finding in hypovolemic shock. The kidneys receive less blood flow due to the decreased circulating volume. As a result, the kidneys reduce urine production to conserve fluid, which is a compensatory mechanism to maintain blood pressure and circulating volume.
- Cool, clammy skin: The skin often becomes cool and clammy because the body constricts blood vessels in the periphery to redirect blood flow to vital organs like the heart and brain. This results in reduced blood flow to the skin.
Incorrect Options:
- A. Hypertension: This is incorrect because, in hypovolemic shock, blood pressure typically decreases due to the loss of circulating volume, not increases.
- B. Bradypnea: This is incorrect because hypovolemic shock usually causes an increase in the respiratory rate (tachypnea), not a decrease.
- D. Flushing of the skin: This is incorrect because the skin is more likely to be pale, cool, and clammy due to peripheral vasoconstriction.
In summary, oliguria is an expected finding in hypovolemic shock as the body attempts to conserve fluid and maintain blood pressure. Recognizing these clinical signs is crucial for timely intervention and treatment, such as fluid resuscitation, to restore adequate circulating volume and prevent organ damage.