A child is brought to the hospital for care after falling down some stairs and is in a state of neurogenic shock. The nurse performs an initial assessment on the client. Which of the following is the best indicator that the client has gone into decompensated shock?

Question

a. An increase in pulse rate
b. A drop in blood pressure
c. A decrease in pulse intensity
d. A rise in body temperature

Answer 1

b. A drop in blood pressure
rationale: Shock can be divided into stages, depending on the body's response to the illness or injury. The symptoms demonstrated during the different stages of shock indicate the stage and also guide the provider toward its treatment. Compensated shock occurs when the body is trying to maintain near-normal vital signs and perfusion, despite the injury to circulation and metabolism, which means the client would only demonstrate a mild drop in blood pressure. Alternatively, decompensated shock is a state in which the body is no longer able to keep up and deterioration occurs, including more profound hypotension. The drop in blood pressure during decompensated shock results in the body no longer able to maintain intravascular pressure to perfuse vital organs.