EAQ N4510 SHOCK

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. A. Bradycardia B. Hypotension C. Spastic paralysis D. Bladder dysfunction E. Increased pulse pressure

A. Bradycardia B. Hypotension D. Bladder dysfunction Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? A. Decreased rate of glomerular filtration B. Excessive blood loss through the burned tissues C. Plasma proteins moving out of the intravascular compartment D. Sodium retention occurring as a result of the aldosterone mechanism

C. Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply. A. Stridor B. Fissuring C. Hypotension D. Dyspnea E. Cracking of the skin

A. Stridor C. Hypotension D. Dyspnea Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? A. Lactated Ringer solution B. Serum albumin C. Blood replacement D. High molecular dextran

C. Blood replacement Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

To prevent septic shock in the hospitalized client, what should the nurse do? A. Maintain the client in a normothermic state. B. Administer blood products to replace fluid losses. C. Use aseptic technique during all invasive procedures. D. Keep the critically ill client immobilized to reduce metabolic demands.

C. Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? A. Septic shock B. Cardiogenic shock C. Neurogenic shock D. Anaphylactic shock

D. Anaphylactic shock Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? A. Oliguria B. Crackles C. Dyspnea D. Bounding pulse

A. Oliguria Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, as well as with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia.

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? A. An irreversible phenomenon B. A failure of the circulatory pump C. Usually a fleeting reaction to tissue injury D. Generally caused by decreased blood volume

B. A failure of the circulatory pump In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia will lead to hypovolemic shock; cardiogenic refers to the heart capabilities.

The nurse notifies the primary healthcare provider that a client has been admitted to the high-risk unit in her thirty-sixth week of gestation. She is bleeding, has severe abdominal pain and a rigid fundus, and is demonstrating signs of impending shock. Which intervention should the nurse prepare for? A. A high-forceps birth B. An immediate cesarean birth C. Insertion of an internal fetal monitor D. Administration of an oxytocin infusion

B. An immediate cesarean birth. An immediate cesarean birth is the ideal treatment for complete placental separation (abruptio placentae). The risk for fetal and maternal mortality is too high to delay action. High-forceps birth is rarely used, because the forceps may further complicate the situation by tearing the cervix. The fetus would probably expire if oxytocin were administered.

During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid associated with the progressive stage of shock. Respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis occurs as a result of hyperventilation during early shock.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? A. Hypokalemia B. Metabolic acidosis C. Respiratory alkalosis D. Decreased Pco2 levels

B. Metabolic acidosis Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco2 level will increase in profound shock.

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? A. The body initially attempts to compensate by releasing more red blood cells. B. The body initially attempts to compensate by maintaining peripheral vasoconstriction. C. The body initially attempts to compensate by decreasing mineralocorticoid production. D. The body initially attempts to compensate by producing less antidiuretic hormone (ADH).

B. The body initially attempts to compensate by maintaining peripheral vasoconstriction. With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure.

A client is considered to be in septic shock when what changes are assessed in the client's labwork? A. Blood glucose is 70-100 mg/dL B. An increased serum lactate level C. An increased neutrophil level D. A white blood count of 5000 cells/µL

B. An increased serum lactate level The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count > 12,000 cells/µL or < 4,000 cells/µL and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL. Blood glucose levels of 70-100 mg/dL are considered normal.

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? A. Hypokalemia B. Metabolic acidosis C. Respiratory alkalosis D. Decreased carbon dioxide level

B. Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? A. Prepare for blood transfusions. B. Notify the surgeon immediately. C. Make the client nothing by mouth (NPO). D. Administer the prescribed preoperative sedative.

B. Notify the surgeon immediately. Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms of shock.

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply. A. Hypertension B. Pulsus paradoxus C. Muffled heart sounds D. Jufular vein distention E. Increased urine output

B. Pulsus paradoxus C. Muffled heart sounds D. Jugular vien distention Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the heart becomes more inefficient, there is a decrease in kidney perfusion and therefore a decrease in urine output.

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. A. Spasticity B. Incontinence C. Flaccid paralysis D. Respiratory failure E. Lack of reflexes below the injury

C. Flaccid paralysis E. Lack of reflexes below the injury Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected.

What is the term for shock associated with a ruptured abdominal aneurysm? A. Vasogenic shock B. Neurogenic shock C. Cardiogenic shock D. Hypovolemic shock

D. Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? A. Uticaria B. Tachycardia C. Restlessness D. Laryngeal edema

D. Laryngeal edema Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? A. Respirations of 10 B. Urine output of 30 mL/hour C. Lethargy D. Restlessness

D. Restlessness In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.