Chapter 14 Shock and Multiple Organ Dysfunction Syndrome

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct?

"The client is in shock because the blood volume has decreased in the system."

What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the patient's prognosis? (Select all that apply.)

- Assess the patient who is at risk for shock. - Administer intravenous fluids. - Monitor for changes in vital signs.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply.

- Famotidine (Pepcid) - Ranitidine (Zantac) - Lansoprazole (Prevacid)

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

- Vital signs - Skin color - Urine output - Peripheral pulses

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first?

100% oxygen via a nonrebreather mask

When vasoactive medications are administered, the nurse must monitor vital signs at least how often?

15 minutes

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.

60 mm Hg

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

70%

Which blood pressure (BP) reading would result in a pulse pressure indicative of shock?

90/70 mm Hg

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

A continuous infusion of total parenteral nutrition

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?

Adrenergic drugs

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits

Adventitious breath sounds

Which colloid is expensive but rapidly expands plasma volume?

Albumin

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

Aortic insufficiency

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

Brain

Older adults are more likely to develop which type of shock?

Cardiogenic shock

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?

Compensatory stage

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to:

Constrict blood vessels in the cardiorespiratory system.

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse

Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix)

The nurse assesses the patient for the negative effect of IV nitroglycerin (Tridil) for shock management which is:

Decreased blood pressure.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. A neighbor calls 911. Which nursing action is helpful while waiting for the ambulance?

Elevate the legs higher than the heart.

A patient presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?

Epinephrine

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?

Epinephrine

A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices?

Hanging tape on the bedside table when changing a wet-to-dry sterile dressing

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

Head injury

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?

Increase the force of myocardial contraction

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client?

Increases myocardial contractility

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?

Intubation and mechanical ventilation

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

Lactated Ringer's

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess

Lung sounds

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation?

Mean arterial pressure of 70 mm Hg

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?

Modified Trendelenburg

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?

Morphine

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?

Neurogenic

The nurse is evaluating a client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?

Organ damage

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Place the client in a modified Trendelenburg position.

Morphine sulfate has which of the following effects on the body?

Reduces preload

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?

Septic

The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock?

Septic

You are assessing a 6-year-old little girl in the emergency department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?

She is having an allergic reaction and going into anaphylactic shock.

When a client is in the compensatory stage of shock, which symptom occurs?

Tachycardia

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family?

The client is not responding to medical interventions.

You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately?

The client's heart rate is greater than 90 beats per minute.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?

The difference between the systolic and diastolic pressure

When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?

Treat the oxygenation needs of the heart muscle

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?

WBC: 42,000/mm3

A client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock?

cardiogenic shock

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:

increase cardiac output.

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

neurogenic shock

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn mediciations would the nurse administer next?

ondansetron (Zofran)