Physiological Adaptation Q 181
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?
A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception
Correct Answer: B. Fluid volume deficit
The vital signs indicate hypovolemic shock. Monitor and document vital signs especially BP and HR. Decrease in circulating blood volume can cause hypotension and tachycardia. Alteration in HR is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.
Option A: The oxygen and nutrients subsequently diffuse from the blood into the interstitial fluid and then into the body cells. Insufficient arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient.
Option C: Ineffective airway clearance is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Appropriate management is vital to prevent potentially life-threatening hypovolemic shock. Older patients are more likely to develop fluid imbalances. The goals of management are to treat the underlying disorder and return the extracellular fluid compartment to normal, to restore fluid volume, and to correct any electrolyte imbalances.
Option D: Alterations sensory / perceptual (visual, auditory, kinesthetic, gustatory, tactile, olfactory) State in which an individual experiences a change in the amount or type of stimuli received, accompanied decrease towards exaggeration or disorder of the response to such stimuli.