Hemorrhagic Shock: Physiology, Compensation, and Shock Index Practice Questions

25 multiple-choice questions on Hemorrhagic shock: physiology, compensation, and shock index for paramedic and EMT students, from Chapter 31 (Bleeding). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Hemorrhagic shock is a form of:

   1. A. Distributive shock
   2. B. Cardiogenic shock
   3. C. Obstructive shock
   4. D. Hypovolemic shock
   Show answer

   Answer: D. Hypovolemic shock

   Hemorrhage reduces circulating volume, so it is hypovolemic shock. Distributive shock, such as septic or neurogenic shock, involves a normal volume in an enlarged container.

2. A patient in shock from a dark-skinned population has no obvious pallor of the face. The best place to look for pallor is the:

   1. A. Conjunctivae, lips, and nail beds
   2. B. Forehead and the backs of the hands
   3. C. Palms after they have been rubbed
   4. D. Skin over the trunk and abdomen
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   Answer: A. Conjunctivae, lips, and nail beds

   Pallor and cyanosis are hard to see on darker skin, so check areas with less pigment: the inner eyelids (conjunctivae), oral mucosa and lips, and nail beds, along with skin temperature and moisture. The forehead, trunk, and backs of the hands show pigment more, and rubbing the palms changes their color and makes them unreliable.

3. A man with a gunshot wound to the abdomen has had HR 140 for 15 minutes. His heart rate suddenly falls to 52/min, and he becomes unresponsive. This change most likely means:

   1. A. His shock is getting better
   2. B. Cardiac arrest is imminent
   3. C. His pain medication is working
   4. D. He is now in neurogenic shock
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   Answer: B. Cardiac arrest is imminent

   In profound hemorrhagic shock, a sudden fall from marked tachycardia to bradycardia reflects a failing, oxygen-starved heart and often comes just before arrest. Prepare for arrest management and expedite definitive care. A falling heart rate with worsening mental status is never improvement, pain relief does not cause this, and nothing suggests a spinal cord injury.

4. A patient in hemorrhagic shock feels cold and has a falling temperature even inside a heated house. The main reason is that:

   1. A. Skin vasodilation is shedding his heat
   2. B. Shock makes the patient sweat heavily
   3. C. Rapid breathing is cooling his core
   4. D. Shock lowers heat production
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   Answer: D. Shock lowers heat production

   Shock reduces oxygen delivery and metabolism, so the body produces less heat, and exposure for assessment adds heat loss. Hypothermia then worsens clotting and bleeding, which is why bleeding patients should be covered early. Hemorrhage constricts rather than dilates skin vessels, rapid breathing adds little heat loss, and while diaphoresis is common, it is not the main cause of the falling temperature.

5. A stabbing victim is tachycardic, pale, and sweaty, and you note obvious pain and fear. Your partner says the fast pulse is just from pain. The best approach is to:

   1. A. Treat it as shock until proven otherwise
   2. B. Give analgesia and see if the rate falls
   3. C. Calm the patient before rechecking vitals
   4. D. Ignore it while his blood pressure is normal
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   Answer: A. Treat it as shock until proven otherwise

   Pain and anxiety do raise the heart rate, but after penetrating trauma tachycardia must be presumed to reflect blood loss. Treat for shock, look for the source, and transport. Pain control and reassurance are appropriate but should not delay recognition, and a normal blood pressure does not exclude compensated shock.

6. Antidiuretic hormone (vasopressin) released during hemorrhage:

   1. A. Causes the kidneys to excrete sodium
   2. B. Increases the heart rate directly
   3. C. Causes the kidneys to retain water
   4. D. Dilates the splanchnic arterioles
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   Answer: C. Causes the kidneys to retain water

   ADH from the posterior pituitary increases water reabsorption and, at high levels, constricts vessels. These effects reduce urine output and support blood pressure.

7. A 25-year-old who was stabbed smells of alcohol and is restless and combative, with HR 128. You should attribute his behavior to:

   1. A. Alcohol, since he smells of it strongly
   2. B. Possible shock or head injury first
   3. C. A psychiatric illness until shown otherwise
   4. D. Pain, since he was recently stabbed
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   Answer: B. Possible shock or head injury first

   Restlessness and combativeness are early signs of cerebral hypoperfusion in hemorrhagic shock and can also come from a head injury or hypoxia. These dangerous causes must be assumed and treated before attributing the behavior to alcohol, which is a common and costly error. Psychiatric illness and pain alone do not explain HR 128 after a stab wound.

8. A bleeding patient is pale and confused. Before attributing the confusion to shock, it is reasonable during transport to also:

   1. A. Withhold all oxygen to avoid excess
   2. B. Perform a full neurologic exam first
   3. C. Check the blood glucose level
   4. D. Obtain orthostatic vital signs
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   Answer: C. Check the blood glucose level

   Altered mental status has several causes that can coexist with blood loss, and hypoglycemia is quick to check and easy to treat, particularly in diabetic or intoxicated patients. A detailed neurologic exam should not delay transport, oxygen should be given to a hypoxic patient, and orthostatic vitals are unsafe and unnecessary in obvious shock.

9. A patient has a heart rate of 120 and a systolic pressure of 100 mmHg. The shock index is:

   1. A. 0.8
   2. B. 1.2
   3. C. 0.5
   4. D. 2.0
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   Answer: B. 1.2

   120 ÷ 100 = 1.2. A shock index above 1.0 is associated with substantial blood loss and need for transfusion, even while the systolic pressure is still 100 mmHg.

10. A trauma patient is pale and tachycardic with a weak radial pulse. Regarding orthostatic vital signs, you should:

    1. A. Skip them; shock is already evident
    2. B. Perform them before deciding on transport
    3. C. Perform them only if he can walk unaided
    4. D. Delay fluids until they have been done
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    Answer: A. Skip them; shock is already evident

    Orthostatic vital signs are a tool for detecting subtle volume loss. In a patient who already shows shock, they add no useful information, risk syncope and a fall, and are inappropriate with possible spinal or lower-limb injuries. They should never delay transport or treatment.

11. A man who fell from a roof cannot move his legs. He is hypotensive with HR 64 and warm legs, and he also has a deformed, swollen thigh. You should:

    1. A. Attribute all of it to neurogenic shock
    2. B. Give a vasopressor before any fluids
    3. C. Hold all fluids because of his spinal injury
    4. D. Assume blood loss as well and treat for it
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    Answer: D. Assume blood loss as well and treat for it

    Neurogenic shock is a diagnosis of exclusion in trauma: hemorrhage is far more common and can coexist, and a femur fracture alone can lose more than a liter. The spinal injury also blunts tachycardia, hiding blood loss. Treat for hemorrhage first, splint, and transport. Vasopressors are considered only after volume is restored, and fluids are not withheld because of a spinal injury.

12. During hemorrhage, the respiratory rate rises mainly to:

    1. A. Blow off CO2 to buffer metabolic acidosis
    2. B. Increase blood flow to the kidneys
    3. C. Raise blood pressure in the lungs
    4. D. Help the heart fill more fully during diastole
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    Answer: A. Blow off CO2 to buffer metabolic acidosis

    Lactic acid from anaerobic metabolism stimulates breathing, and exhaling CO2 partly corrects the pH. A rising respiratory rate is an early but often overlooked sign of shock.

13. A bleeding trauma patient with adequate ventilation has an ETCO2 of 22 mmHg. This most likely reflects:

    1. A. Hypoventilation from narcotic use
    2. B. Normal metabolism with good perfusion
    3. C. Increased CO2 production from fever
    4. D. Poor perfusion and low cardiac output
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    Answer: D. Poor perfusion and low cardiac output

    CO2 must be carried to the lungs by blood flow; when cardiac output falls, less CO2 reaches the alveoli and ETCO2 drops. Hypoventilation would raise ETCO2, not lower it.

14. A trauma patient is pale and cool, with HR 116 and BP 118/84 mmHg. You want an early indication of whether bleeding is continuing during transport. The best indicator is:

    1. A. A single normal blood pressure reading
    2. B. A heart rate rising on repeat checks
    3. C. An SpO2 that remains at 98% on oxygen
    4. D. The color of the blood on his clothing
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    Answer: B. A heart rate rising on repeat checks

    Heart rate and pulse pressure trends change before blood pressure falls, so a steadily climbing heart rate, together with worsening mental status and skin signs, suggests ongoing loss. A single normal blood pressure is reassuring only falsely, SpO2 measures saturation rather than perfusion, and the color of spilled blood says nothing about whether bleeding continues.

15. In late shock, precapillary sphincters relax while postcapillary sphincters stay constricted. The result is:

    1. A. Improved flow and better oxygen delivery
    2. B. Faster return of venous blood to the right heart
    3. C. Blood pooling and fluid leaking from capillaries
    4. D. Higher pressure in the large arteries
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    Answer: C. Blood pooling and fluid leaking from capillaries

    Blood enters the capillary beds but cannot leave, so it stagnates, hydrostatic pressure rises, and plasma leaks into the tissues. This worsens hypovolemia and marks progression toward irreversible shock.

16. A healthy 19-year-old with a gunshot wound to the abdomen has HR 112 and BP 118/84 mmHg. Why is this patient especially easy to underestimate?

    1. A. Young adults vasodilate early as shock develops
    2. B. His normal blood pressure shows the loss is under 15%
    3. C. Young adults compensate well, then decline abruptly
    4. D. Young adults carry a larger blood volume per kg
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    Answer: C. Young adults compensate well, then decline abruptly

    Young patients with good cardiovascular reserve can hold a normal blood pressure until a large share of volume is lost, then crash suddenly. Treat the tachycardia and mechanism as shock. A normal pressure does not cap the loss at 15%, young adults constrict rather than dilate their vessels in shock, and their blood volume per kilogram is about the same as other adults.

17. A 22-year-old with a stab wound has HR 124 and a normal blood pressure. Compared with an older adult with the same blood loss, he is likely to:

    1. A. Show hypotension much earlier in shock
    2. B. Look stable longer, then crash
    3. C. Compensate poorly from the very start
    4. D. Never decompensate if he stays still
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    Answer: B. Look stable longer, then crash

    Healthy young adults have strong compensatory reserves, so blood pressure can stay normal until a large share of volume is lost, followed by sudden decompensation. Older adults compensate less well and may become hypotensive earlier. Lying still does not prevent decompensation if bleeding continues, so early recognition and transport matter.

18. Before you can control a wound, a bleeding patient becomes pale and starts to faint while standing. The best immediate position for him is:

    1. A. Sitting upright to ease his breathing
    2. B. Sitting with his head between his knees
    3. C. Kneeling with support while you work
    4. D. Lying flat while you stop the bleeding
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    Answer: D. Lying flat while you stop the bleeding

    Lying the patient flat keeps blood in the central circulation, prevents a fall, and lets you apply direct pressure or a tourniquet. Sitting, head-between-knees, or kneeling positions keep the brain above a volume-depleted circulation, worsen cerebral perfusion, and risk a fall if he faints.

19. Thirst in a bleeding patient is caused by:

    1. A. Hormonal and osmotic responses to volume loss
    2. B. Dry mouth from breathing through the open mouth
    3. C. Low blood glucose from the injury
    4. D. A reaction to the pain medication
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    Answer: A. Hormonal and osmotic responses to volume loss

    Angiotensin II and hypothalamic sensors trigger thirst as volume falls. These patients should still receive nothing by mouth because they may need surgery.

20. Mottled skin on the knees and trunk of a hemorrhaging patient indicates:

    1. A. Severe peripheral hypoperfusion
    2. B. Normal skin on cold exposure
    3. C. Early and mild vasoconstriction
    4. D. Bruising from the initial injury
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    Answer: A. Severe peripheral hypoperfusion

    Mottling reflects severe vasoconstriction and poor skin perfusion and is a late sign of shock. Cold can make skin pale, but mottling in a bleeding patient should be treated as critical. It is not a mild or early finding, and its lacy, symmetric pattern on the knees and trunk differs from bruising at an injury site.

21. Blood flow to the brain and heart is spared during the sympathetic response to hemorrhage mainly because:

    1. A. They have their own separate blood supply
    2. B. They store large reserves of oxygen
    3. C. Their vessels are lined with extra smooth muscle layers
    4. D. Their vessels autoregulate and resist constriction
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    Answer: D. Their vessels autoregulate and resist constriction

    Cerebral and coronary vessels autoregulate and respond little to sympathetic vasoconstriction, so flow is redirected to them as skin, gut, and kidneys constrict. Neither organ stores meaningful oxygen, which is why they fail quickly once pressure falls.

22. A man with a scalp laceration is in profound shock even though the scalp bleeding has been controlled. You should:

    1. A. Attribute the shock to the scalp wound alone
    2. B. Assume a brain injury is causing the shock
    3. C. Search for another source of blood loss
    4. D. Treat him for neurogenic shock first
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    Answer: C. Search for another source of blood loss

    Once a scalp wound is controlled, ongoing shock means another source; look at the chest, abdomen, pelvis, and long bones. Brain injury causes hypotension only in its terminal stages, so blaming the head misses treatable bleeding.

23. A patient with a penetrating wound has an initial lactate of 6 mmol/L. This indicates:

    1. A. Normal aerobic metabolism
    2. B. Widespread tissue hypoperfusion
    3. C. Mild and fully compensated shock
    4. D. A normal stress response to pain
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    Answer: B. Widespread tissue hypoperfusion

    Lactate above 4 mmol/L indicates severe hypoperfusion and anaerobic metabolism and is linked to higher mortality. It can be elevated before the blood pressure falls. A value of 6 mmol/L is neither mild nor compensated, and pain alone does not raise lactate to this level.

24. A woman with a stab wound to the thigh becomes lethargic, with HR 148 and BP 64/40 mmHg. Your highest priorities are:

    1. A. A complete secondary assessment on scene
    2. B. Orthostatic vital signs before moving
    3. C. Two large IV lines before leaving scene
    4. D. Hemorrhage control and rapid transport
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    Answer: D. Hemorrhage control and rapid transport

    This is decompensated, class IV shock; the treatment is stopping the bleeding and getting her to blood and surgery. IV access should be done en route, not at the cost of scene time.

25. A patient in shock remains tachycardic and hypotensive after you control his only visible wound. The most likely explanation is:

    1. A. A normal lag before his vitals recover
    2. B. His shock is from anxiety alone
    3. C. Ongoing hidden internal bleeding
    4. D. Vasodilation from the pain he is in
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    Answer: C. Ongoing hidden internal bleeding

    When shock persists after visible bleeding is controlled, look for hidden loss in the chest, abdomen, pelvis, and thighs (and tension pneumothorax or tamponade as non-hemorrhagic causes). Anxiety does not cause hypotension, pain drives vasoconstriction rather than vasodilation, and persistent shock should never be dismissed as a delay before recovery.