NCLEX-RNPhysiological AdaptationMedium
A client is admitted following a motor vehicle collision with significant blood loss. Vital signs are blood pressure 112/74 mmHg, heart rate 118/min, respiratory rate 22/min, and capillary refill 3 seconds. The client appears anxious. Which finding represents the earliest indicator of compensatory shock?
- AHeart rate of 118/min
- BClient anxiety
- CBlood pressure of 112/74 mmHg
- DCapillary refill of 3 seconds
Show answer & explanationAnswer & explanation
Correct answer: A. Heart rate of 118/min
In compensatory shock, tachycardia is the earliest physiologic response as the body attempts to maintain cardiac output and perfusion before blood pressure drops. Blood pressure often remains normal until later stages due to compensatory vasoconstriction.
Why the other options are wrong
- B. Anxiety can result from many causes and is a nonspecific, later finding compared to tachycardia.
- C. Blood pressure remains normal in early compensatory shock due to effective compensatory mechanisms, masking the deficit.
- D. Delayed capillary refill occurs but is a later, less sensitive indicator than heart rate change.
Compensatory Shock
The earliest stage of shock in which the body activates sympathetic responses (tachycardia, vasoconstriction) to maintain perfusion while blood pressure remains normal.
- Tachycardia is the earliest sign of shock
- BP stays normal until compensatory mechanisms fail
- Progresses to decompensated then irreversible shock if untreated
Memory trick: Heart races first, pressure falls last