What will the nurse identify as symptoms of hypovolemic shock in a patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply

Question

1. Temperature of 97.6°F (36.4°C)
2. Restlessness
3. Decrease in blood pressure of 20 mm Hg when the patient sits up
4. Capillary refill time greater than 3 seconds
5. Sinus bradycardia of 55 beats per minute

Answer 1

2,3,4
Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate.
Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status.
Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock.
Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced.
Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.