The client has just received news of the death of a relative. Over the next few hours, what physiologic response should the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event?

Question

1. Drop in blood pressure from 130/80 to 120/75
2. A more bounding pulse
3. Slight increase in urine output
4. Some decrease in oxygen saturation

Answer 1

Correct Answer: 2
Rationale 1: Blood pressure rises in response to angiotensin production.
Rationale 2: During this shock phase, the sympathetic nervous system is stimulated, resulting in increased myocardial contractility, which would be reflected in the client as a bounding pulse.
Rationale 3: Norepinephrine release decreases blood flow to the kidney, which could make urine output decrease.
Rationale 4: The bronchial tree dilates, allowing more oxygen intake that would result in increased oxygen saturation.