The nurse is caring for a client in the compensatory stage of hypovolemic shock following a gastrointestinal bleed.
The nurse would expect
The nurse is caring for a client in the compensatory stage of hypovolemic shock following a gastrointestinal bleed.
The nurse would expect
A. bounding peripheral pulses and warm, flushed skin
[20%]
B. bradycardia and hypotension unresponsive to fluids
[13%]
C. tachycardia and cool, clammy extremities
[62%]
D. absent bowel sounds and severe metabolic acidosis
[5%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
Analysis
Explanation
Choice C is correct. The nurse would expect tachycardia and cool, clammy extremities. In the compensatory stage of shock, the body activates the sympathetic nervous system in response to decreased perfusion. This results in tachycardia to maintain cardiac output and peripheral vasoconstriction, causing cool, clammy skin.
Choice A is incorrect. A bounding pulse and warm, flushed skin are signs of early distributive (septic) shock, not hypovolemic shock in the compensatory phase, where pulses are typically weak and skin is cool.
Choice B is incorrect. Bradycardia and hypotension that is unresponsive to fluids describes the progressive or refractory stage of shock, not the compensatory stage. In the compensatory stage, blood pressure may still be maintained through vasoconstriction.
Choice D is incorrect. Absent bowel sounds and severe metabolic acidosis are more consistent with late-stage or progressive shock when perfusion to the gastrointestinal tract is critically reduced and cellular hypoxia leads to worsening acidosis.
Learning Objective
Identify the expected clinical manifestations associated with the compensatory stage of shock.
Related Videos
4 Key Topics
Shock
12.5 Infection, Bleeding & Shock Risks
Shock Overview
27.5 Shock
Additional Info
✓ In the compensatory stage of shock, baroreceptors detect decreased perfusion and stimulate the release of catecholamines (epinephrine and norepinephrine), leading to tachycardia, vasoconstriction, and increased respiratory rate.
✓ Despite significant fluid loss, blood pressure can remain near normal in the compensatory phase because of vasoconstriction. Reliance on BP alone may delay recognition.
✓ An increasing heart rate is usually the first vital sign to change in early shock and should never be ignored, especially if paired with other subtle signs like cool extremities or altered capillary refill.
✓ Recognizing compensatory signs enables early fluid resuscitation and treatment of the underlying cause, preventing transition to the progressive or irreversible stages.
