The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock? $$\begin{array} { | l | l | }
\hline \text { Assessments for Shock } & \text { Patient Manifestations } \
\hline \text { Blood loss } & 1950 \mathrm {~mL} \
\hline \text { Percent of blood volume } & 32 \% \
\text { loss } & \
\hline \text { Heart rate } & 136 \
\hline \text { Blood pressure } & 80 / 65 \
\hline \text { Capillary refill } & 5 \text { seconds } \
\hline \text { Respiratory rate } & 28 \mathrm { per } \text { minute } \
\hline \text { Urine output } ( \mathrm { mL } / \mathrm { h } ) & 12 \mathrm {~mL} / \mathrm { h } \
\hline \text { Mental status } & \text { Confused } \
\hline
\end{array}$$

Question

The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock? $$\begin{array} { | l | l | } 
\hline \text { Assessments for Shock } & \text { Patient Manifestations } \
\hline \text { Blood loss } & 1950 \mathrm {~mL} \
\hline \text { Percent of blood volume } & 32 \% \
\text { loss } & \
\hline \text { Heart rate } & 136 \
\hline \text { Blood pressure } & 80 / 65 \
\hline \text { Capillary refill } & > 5 \text { seconds } \
\hline \text { Respiratory rate } & 28 \mathrm { per } \text { minute } \
\hline \text { Urine output } ( \mathrm { mL } / \mathrm { h } ) & 12 \mathrm {~mL} / \mathrm { h } \
\hline \text { Mental status } & \text { Confused } \
\hline
\end{array}$$

Quizplus · Accepted Answer

The patient is in the progressive stage of shock based on the following manifestations:
- Blood loss of 1950 mL (greater than 30% of blood volume)
- Tachycardia (heart rate of 136 bpm)
- Hypotension (blood pressure of 80/65 mmHg)
- Delayed capillary refill (>5 seconds)
- Tachypnea (respiratory rate of 28 bpm)
- Decreased urine output (12 mL/hour)
- Altered mental status (confused)

In the progressive stage, compensatory mechanisms are no longer able to maintain adequate tissue perfusion and organ function begins to fail, resulting in worsening of clinical manifestations. Refractory shock is the final stage, characterized by irreversible damage and failure of multiple organ systems, leading to death.

The Nurse Is Reviewing Data for a Patient Experiencing Shock