A patient who has gastrointestinal bleeding is awake, alert, and oriented. The patient's vital signs are: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C)
Which of this patient's data collection findings should the nurse consider as a possible sign of early shock?
a. Blood pressure 130/90 mm Hg
b. Heart rate 118 beats/min
c. Respirations 18/min
d. Temperature 98.6°F (37°C)
ANS: B
When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor.
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