Chapter 19: Shock

27. A nurse explains that the minimal acceptable hourly urine output for a patient in shock who weighs 220 lb is _____.

ANS: 5 mL 220 lb ÷ 2.2 lb = 10 kg; 0.5 mL/kg/hr 10 = 5 mL. DIF: Cognitive Level: Analysis REF: p. 309 OBJ: 7 TOP: Minimum Urine Output KEY: Nursing Process Step: Implementation

28. A nurse is aware that immobility and insertion of urinary catheters, although therapeutic, also places the patient at risk for _____.

ANS: infection The insertion of a Foley catheter and long-term immobility can cause infections. DIF: Cognitive Level: Comprehension REF: p. 309 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Planning

26. A nurse explains that when shock forces the body into anaerobic metabolism, organ damage is caused by a product of that metabolism, which is _____.

ANS: lactic acid Lactic acid, a by-product of anaerobic metabolism, can cause organ damage in the patient who is in shock. DIF: Cognitive Level: Knowledge REF: p. 304 OBJ: 2 TOP: Lactic Acid KEY: Nursing Process Step: Implementation

25. A nurse explains that pericardial tamponade and pulmonary embolus can place the patient at risk for _____ shock.

ANS: obstructive Obstructive shock can result from pericardial tamponade or pulmonary embolus. DIF: Cognitive Level: Knowledge REF: p. 301-302 OBJ: 1 | 2 TOP: Obstructive Shock KEY: Nursing Process Step: Implementation

20. A patient is in the compensatory stage of shock. What symptoms displayed by the patient would indicate the need to implement immediate nursing action? a. Irritable and restless b. Listless and confused c. Unconscious d. Anxious and fearful

ANS: A An irritable and restless patient is at definite risk for falling or hurting him- or herself. DIF: Cognitive Level: Comprehension REF: p. 303 OBJ: 3 TOP: Compensatory Stage Symptoms KEY: Nursing Process Step: Implementation

13. In treating a person outside of a medical facility, a nurse knows that immediate circulatory support for the vital organs must begin as quickly as possible because, without oxygen, the brain cells will begin to die in how many minutes? a. 4 b. 6 c. 14 d. 24

ANS: A Brain cells must have oxygen to live; they are very sensitive to lack of oxygen and begin to die in 4 minutes. DIF: Cognitive Level: Knowledge REF: N/A OBJ: 2 TOP: Brain Death without Oxygen KEY: Nursing Process Step: Assessment

18. Which nursing interventions will best assist a patient cope with decreased cardiac output? a. Dovetailing nursing care tasks allows rest periods for the patient. b. Maintaining enough cover prevents the patient from shivering. c. Turning, coughing, deep breathing, and ambulating the patient every 2 hours reduce the risk of embolism. d. Analgesics should be administered cautiously.

ANS: A Care should be designed to reduce the metabolic demands on the failing heart. Shivering and physical activity increase the demands; analgesics may reduce output more. DIF: Cognitive Level: Comprehension REF: p. 308 OBJ: 6 TOP: Nursing Patients with Decreased Cardiac Output KEY: Nursing Process Step: Implementation

11. A nurse is explaining the rationale behind the use of Hypothermic devices to a patient's family. When relaying information what explanation should the nurse provide when asked why this garment provides compression to the legs and abdomen? a. To help restore cellular perfusion b. Decreases internal hemorrhage c. Cools the patient to create less metabolic demand d. Applies pressure during the systole phase and relax pressure during the diastole phase

ANS: A Hypothermic devices compress the vessels in the legs and abdomen to increase both blood pressure and cardiac output. DIF: Cognitive Level: Comprehension REF: p. 308 OBJ: 6 TOP: Hypothermic devices KEY: Nursing Process Step: Implementation

21. A patient in the progressive stage of shock is receiving medication to manage the symptoms. What is the desired effect of the medication? a. Increase in cardiac output b. Decrease in blood pressure c. Decrease in urine output d. Lower temperature

ANS: A Increasing cardiac output requires aggressive action to prevent MODS. Dopamine increases heart contractibility and rate. DIF: Cognitive Level: Comprehension REF: p. 304-307 OBJ: 6 TOP: Treatment of Progressive Shock KEY: Nursing Process Step: Planning

12. A nurse is speaking to the family of a 65-year-old Latino woman. To whom should the nurse address most of the conversation to keeping in mind cultural considerations? a. 66-year-old husband b. Entire family, in general c. 42-year-old daughter (oldest child) d. 40-year-old son (only son)

ANS: A Many older Latino families recognize the older men in the family, the father or husband, as the decision makers. DIF: Cognitive Level: Comprehension REF: p. 310 OBJ: 7 TOP: Cultural Considerations KEY: Nursing Process Step: Planning

15. What causes the cool, damp skin of patients in compensatory shock? a. Constriction of peripheral blood vessels because of the shunting of blood to the vital organs b. Action of the antidiuretic hormone released in shock by the adrenal glands c. Decreasing levels of arterial carbon dioxide, which are pooling in the arms and legs d. Activation of the baroreceptors in the renal arteries

ANS: A When overall blood volume is reduced in shock, the remaining blood volume is shunted to vital organs. DIF: Cognitive Level: Comprehension REF: p. 303-304 OBJ: 2 TOP: Rationale for Skin Changes in Compensatory Shock KEY: Nursing Process Step: Assessment

2. Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock, shock itself results from failure of which system? a. Circulatory b. Endocrine c. Neurologic d. Respiratory

ANS: A When the heart fails as a pump, the lack of tissue perfusion follows and deprives all the body's cells of oxygen and the removal of wastes. DIF: Cognitive Level: Knowledge REF: p. 301 OBJ: 2 TOP: Definition of Shock KEY: Nursing Process Step: N/A

19. One of the most important assessments that a nurse makes is to check urine output. Which value objectively validates minimal acceptable renal perfusion for the average-size person? a. 0.5 mL/kg/hr b. 0.5 mL/lb/hr c. 1 mL/lb/hr d. 0.2 mL/kg/hr

ANS: A When the kidneys produce at least 0.5 mL/kg/hr of urine, the indication is that the vital organs are also being perfused. DIF: Cognitive Level: Knowledge REF: p. 308 OBJ: 5 TOP: Urine Output As Measure of Tissue Perfusion KEY: Nursing Process Step: Implementation

17. A nurse is administering heparin, subcutaneous twice daily, to a patient in cardiogenic shock. What is the expected action of this drug? a. Inotropic to improve cardiac contractibility b. Anticoagulant to prevent blood clots c. Antidysrhythmic to restore normal cardiac contractibility d. Vasopressor to increase blood pressure

ANS: B Cardiogenic shock may produce clots because of blood stasis, and the heparin will delay clot formation. DIF: Cognitive Level: Knowledge REF: p. 311 OBJ: 5 | 6 TOP: Heparin for Anticoagulation KEY: Nursing Process Step: Implementation

22. A family member asks why her father, who is being treated for cardiogenic shock, needs parenteral feeding because he is capable of eating small amounts. What is the best response by the nurse? a. "Parenteral feedings reduce the risk of constipation." b. "Parenteral feedings meet the patient's hypermetabolic needs." c. "Parenteral feedings are more convenient and less time consuming." d. "Parenteral feedings decrease the hazard of infection."

ANS: B Hyperbolic nutritional needs of the person in shock are best met by parenteral feedings, which guarantee adequate calories. DIF: Cognitive Level: Comprehension REF: p. 312 OBJ: 6 TOP: Parenteral Feedings KEY: Nursing Process Step: Implementation

24. An older Japanese patient in progressive shock lingers on the verge of death. What intervention does the patient's cultural background dictate? a. Allow any and all cultural rituals at the bedside. b. Encourage the family to talk to the patient who can be comforted by their familiar voices. c. Restrict the ministrations of the folk healer. d. Suggest that small children not see the patient.

ANS: B Japanese cultural behavior for the dying patient advocates that the entire family be in attendance and take part in the nursing care. DIF: Cognitive Level: Application REF: p. 310 OBJ: 7 TOP: Psychologic Care of the Patient in Shock KEY: Nursing Process Step: Implementation

7. How does the intraaortic balloon pump (IABP) assist a patient who is in cardiogenic shock to increase cardiac output? a. Provides generalized vasoconstriction b. Inflates during the diastole phase c. Constricts the vena cava d. Adds hypertonic fluid to the circulating volume

ANS: B The IABP inflates during diastole (relaxation) phase and deflates during the systole (constriction) phase, which improves cardiac output. DIF: Cognitive Level: Comprehension REF: p. 306 | p. 308 OBJ: 6 TOP: IABP KEY: Nursing Process Step: Implementation

16. Which position enhances cerebral blood flow to counteract the symptoms of compensatory shock? a. Fowler b. Trendelenburg c. Gravity neutral d. Side lying

ANS: B The Trendelenburg position, with the patient's head down, allows gravity to pull blood to the cerebrum. All other positions are ineffective for improving cerebral perfusion. DIF: Cognitive Level: Knowledge REF: p. 311 OBJ: 5 TOP: Positions to Counteract Shock KEY: Nursing Process Step: Implementation

3. A nurse is assessing a patient who is in shock. What should the nurse be aware that one common sign will be, regardless of the cause of the shock? a. The skin is cool and dry with cyanotic nail beds. b. The skin is cool and moist with cyanotic nail beds. c. The nail beds are reddened, and the skin is moist and warm. d. The nail beds are reddened, and the skin is dry and warm.

ANS: B Venous blood pools in the extremities of the fingers as a result of the lack of adequate perfusion of tissues, which makes the skin cool and moist from a lack of oxygen and waste exchanges. DIF: Cognitive Level: Comprehension REF: p. 304-305 OBJ: 3 TOP: Common Signs of Shock KEY: Nursing Process Step: Assessment

6. A licensed practical/vocational nurse (LPN/LVN) is assisting in developing a nursing care plan for a patient in shock. Which nursing diagnosis should be included? a. Increased cardiac output, related to hypertension b. Increased cardiac output, related to hypotension c. Decreased cardiac output, related to hypovolemia d. Decreased cardiac output, related to hypertension

ANS: C Decreased amount of blood is ejected from the heart because of a decreased volume of fluid in the intravascular compartment. DIF: Cognitive Level: Application REF: p. 308 OBJ: 7 TOP: Nursing Diagnosis for Patients in Shock KEY: Nursing Process Step: Planning

10. While shopping in the mall, a nurse sees a lady suddenly fall to the floor. On immediate assessment, the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR). What should be the immediate actions by the nurse? a. Check the pulse and respirations and call for a blood pressure cuff. b. Check the pulse, respirations, skin color, and temperature. c. Call for help and check the pulse, respiration, and mental status. d. Ask someone to help place large blankets or coats under her legs and trunk.

ANS: C Shock treatment requires expert medical implementation. However, the nurse may provide first-line support until such help arrives. Circulatory collapse has to be monitored first; pulse, respiration, and mental status should be assessed to evaluate whether oxygen is reaching the brain. DIF: Cognitive Level: Application REF: p. 305 OBJ: 4 TOP: Emergency Aid for Shock Victim KEY: Nursing Process Step: Implementation

14. The stages of shock proceed in a definite sequence. What is the correct order? a. Progressive, compensatory, refractory b. Refractory, progressive, compensatory c. Compensatory, progressive, refractory d. Distributive, compensatory, refractory

ANS: C Understanding the sequence of the progression of shock allows the medical team to plan and implement the correct steps to reverse it. DIF: Cognitive Level: Knowledge REF: p. 303 OBJ: 1 TOP: Stages of Shock KEY: Nursing Process Step: N/A

4. What should a nurse assessing a patient in the progressive stage of shock expect to find? a. Bounding pulse, decreased respirations, and decreased blood pressure b. Bounding pulse, shallow respirations, and significantly increased blood pressure c. Thready pulse and deep respirations with decreased blood pressure d. Thready pulse and irregular respirations with increased blood pressure

ANS: C When the heart fails as a pump, the pulse is weak; the respirations increase in an effort to decrease the carbon dioxide level; and, with less volume being pumped, the blood pressure falls. DIF: Cognitive Level: Comprehension REF: p. 304 OBJ: 3 TOP: Signs of Shock KEY: Nursing Process Step: Assessment

8. A nurse is explaining to a family member the pathophysiologic characteristic of vasogenic shock. What information should the nurse include? a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs. b. The circulating volume causes excessive constriction of the vessels, causing blood pooling. c. Widely fluctuating blood pressures stimulate vascular collapse, causing severe alterations in peripheral perfusion. d. Although the circulating volume is intact, excessive vascular dilation causes drastic drops in the blood pressure.

ANS: D Blood pooling from dilated vessels drops the blood pressure without loss of circulating volume. DIF: Cognitive Level: Knowledge REF: p. 302 OBJ: 2 TOP: Vasogenic Shock KEY: Nursing Process Step: Implementation

5. What should a nurse expect of a patient's respirations caused by the falling blood pressure and impaired blood circulation during the refractory stage of shock? a. Rapid and deep b. Rapid and shallow c. Slow and deep d. Slow and shallow

ANS: D During the refractory stage of shock, as the body systems are failing, the respirations become slow, shallow, and irregular. Death is imminent at this stage. DIF: Cognitive Level: Application REF: p. 305 OBJ: 2 TOP: Respirations in Shock KEY: Nursing Process Step: Assessment

9. A nurse is caring for a patient who has a cervical spine injury and assesses progressive hypotension. What does this signify? a. Anaphylaxis b. Respiratory alkalosis c. Multiple organ dysfunction syndrome (MODS) d. Neurogenic shock

ANS: D Gradually decreasing blood pressure in a person with a spinal injury is an indicator of neurogenic shock related to the parasympathetic stimulation, which causes generalized vasodilation. DIF: Cognitive Level: Comprehension REF: p. 303 OBJ: 3 TOP: Implementation KEY: Nursing Process Step: Evaluation

23. A patient's family voices concern regarding the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS). What explanation by the nurse is most appropriate when explaining the rationale of treatment? a. "Applying a MAST garment is mandatory to promote and conserve body heat." b. "Inserting an IABP is required to decrease fluid leaking into the extravascular space." c. "Maintaining strict isolation is vital to prevent an overlying bacterial infection." d. "Aggressive treatment is necessary to support the multiple failing organs."

ANS: D SIRS is the final and possibly fatal stage of shock. The body's defenses are supported aggressively and rapidly. MAST and IABP are measures used to increase circulating volume. Isolation is not indicated. DIF: Cognitive Level: Comprehension REF: p. 312 OBJ: 6 TOP: SIRS Treatment KEY: Nursing Process Step: Implementation

1. What are the four types of shock? a. Multiple organ, cardiogenic, renal, and anaphylactic b. Cardiogenic, renal, hypovolemic, and septic c. Renal, hypervolemic, obstructive shock, and neurogenic d. Hypovolemic, cardiogenic, obstructive shock, and vasogenic

ANS: D The four large categories of shock are hypovolemic (low-circulating volume), cardiogenic (low-cardiac output), obstructive (occluded vascular pathway), and vasogenic (massive vasodilation). DIF: Cognitive Level: Knowledge REF: p. 301 OBJ: 1 TOP: Types of Shock KEY: Nursing Process Step: Planning