Shock

Factors that influence MAP:

* total blood volume * cardiac output * size of the vascular bed Increase in TBV or CO = increase in MAP Decrease in TBV or CO = decrease in MAP

Respiratory manifestations of shock:

*increased respiratory rate * shallow depth of respirations * increased or decreased PaO2 * cyanosis, esp around lips/nail beds

Hypovolemic shock:

When too little circulating blood volume causes a MAP decrease, resulting in inadequate total body oxygenation. Total body fluid decreased (in all fluid compartments).

Specific cause or risk factors for hypovolemic shock:

* Hemorrhage: trauma, GI ulcer, inadequate clotting, liver disease, cancer * dehydration: vomiting, diarrhea, hyperglycemia

Shock classifications:

* Hypovolemic shock * Cardiogenic shock * distributive shock (includes septic, neurogenic & anaphylactic) * obstructive shock

Specific cause or risk factors for Cardiogenic shock:

* Myocardial infarction * cardiac arrest * ventricular dysrhythmias ( fib, tachy) * cardiac amyloidosis * cardiomyopathies * myocardial degeneration

Neuromuscular manifestations of shock: EARLY

* anxiety * restlessness * increased thirst

Specific causes or risk factors of obstructive shock:

* cardiac tamponade * arterial stenosis * pulmonary embolus * pulmonary hypertension * constrictive pericarditis * thoracic tumors * tension pneumothorax

Integumentary manifestations of shock:

* cool to cold * pale to mottled to cyanotic * moist, clammy * mouth dry; paste like coating

Neuromuscular manifestations of shock: LATE

* decreased CNS activity (lethargy to coma) * generalized muscle weakness * diminished or absent deep tendon reflexes * sluggish pupillary response to light

Cardiovascular manifestations of shock:

* decreased CO * increased pulse * thread pulse * decreased BP * narrowed pulse pressure * flat neck and hand veins in dependent positions * diminished peripheral pulses

Specific causes or risk factors for distributive shock:

* neural-induced: pain, anesthesia, stress, spinal cord inure * chemical-induced: anaphylaxis, sepsis, capillary leak (burns, extensive trauma, liver impairment

Which organ is responsible for releasing myocardial depressant factor that leads to heart damage as a result of multiple organ dysfunction syndrome (MODS)? 1 Liver 2 Brain 3 Kidney 4 Pancreas

4. Pancreas Rationale: Myocardial depressant factor is secreted from the ischemic pancreas and is responsible for causing profound damage to the heart in MODS. The liver, brain, and kidneys, in addition to the heart, are severely damaged but they do not release myocardial depressant factors.

What metabolic changes occur as a result of tissue ischemia during the compensatory stage of hypovolemic shock? Select all that apply. 1 Acidosis 2 Alkalosis 3 Hypokalemia 4 Hyperkalemia 5 Vasodilatation

1. Acidosis 4. Hyperkalemia Rationale: In the compensatory (nonprogressive) stage of shock, tissue hypoxia leads to acidosis because of changes in anaerobic metabolism. Hyperkalemia occurs as well from the changes in metabolism. The client is acidotic, not alkalotic. Hypovolemic shock is associated with vasoconstriction, not vasodilation.

Where are the baroreceptors that are responsible for detection of pressure changes within the arterial system located? 1 Aortic arch 2 Radial sinus 3 Brachial arch 4 Femoral sinus

1. Aortic arch Rationale: The baroreceptors responsible for detecting pressure changes in the arterial system are located in aortic arch and carotid sinus. There are no baroreceptors located in radial sinus, brachial arch, and femoral sinus.

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. 1 Ask family members to stay with the client. 2 Call the health care provider. 3 Increase IV and oxygen rates. 4 Remain with the client. 5 Reassure the client that everything is being done for him or her.

1. Ask family members to stay with the client. 4. Remain with the client. 5. Reassure the client that everything is being done for him or her. Rationale: Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen may be needed, but these actions do not support the client's psychosocial integrity.

After norepinephrine (Levophed) is administered to a client with hypovolemic shock, which assessment factor is used to verify the effectiveness of the treatment? 1 Blood pressure 2 Urinary output 3 Level of consciousness 4 Blood glucose

1. Blood pressure Rationale: Norepinephrine (Levophed) is a vasoconstrictor drug used in hypovolemic shock to increase perfusion and oxygenation. These drugs constrict the blood vessels and increase venous return. Urine production will not increase until blood pressure rises and perfuses the kidneys. Norepinephrine does not have any effect on a client's level of consciousness or blood glucose levels.

The nurse is administering continuous intravenous infusion of norepinephrine (Levophed) to a client in shock. Which finding causes the nurse to decrease the rate of infusion? 1 Blood pressure 170/96 mm Hg 2 Respiratory rate 22 breaths/min 3 Urine output of 70 mL/hr 4 Heart rate 98 beats/min

1. Blood pressure 170/96 mm Hg Rationale: Signs of excess vasoconstricting drugs include headache, hypertension, and decreased renal perfusion manifested by oliguria. While vasoconstricting medications and the shock state may cause tachycardia (heart rate greater than 100 beats/min), this client's heart rate is within normal range. Vasoconstricting drugs do not affect the respiratory rate; shock itself causes an increased respiratory rate in an effort to deliver more oxygen to the tissues.

A client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? 1 Broad-spectrum antibiotics 2 Blood transfusion 3 Cooling baths 4 Nothing by mouth (NPO) status

1. Broad-spectrum antibiotics Rationale: Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell (RBC) count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle.

How is a client with systemic inflammatory response syndrome (SIRS) differentiated from a client with sepsis? 1 Client with sepsis has hypotension. 2 Client with sepsis has a negative fluid balance. 3 Client with SIRS has hyperglycemia. 4 Client with SIRS has an elevated creatinine level.

1. Client with sepsis has hypotension. Rationale: The client with sepsis has two or more SIRS criteria and one of the following: hypotension, oliguria, positive fluid balance, decreased capillary refill, hyperglycemia, change in mental status, or increasing creatinine. The SIRS criteria include temperature of >100.4° F or < 96.8° F, pulse >90 beats/min, respiratory rate >20 breaths/min or a Paco2 <32 mm Hg, or white blood cell count of >12,000/mm3 or <4000/mm3.

The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22/min. What does the supervising nurse do? 1 Compare these vital signs with the last several readings. 2 Request the surgeon see the client. 3 Increase the rate of intravenous fluids. 4 Reassess vital signs using different equipment.

1. Compare these vital signs with the last several readings. Rationale: Vital sign trends must be taken into consideration; a BP of 90/60 may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.

Which assessment findings are consistent with the nonprogressive (compensatory) phase of shock? Select all that apply. 1 Cool skin 2 Bradycardia 3 Elevated liver function tests 4 Restlessness 5 Tachypnea 6 Anxiety

1. Cool skin 4. Restlessness 5. Tachypnea 6. Anxiety Rationale: Thirst, anxiety, restlessness, tachycardia, and increased respiratory rate (tachypnea) along with oliguria and narrowing pulse pressure appear in the nonprogressive (compensatory) stage of shock. Organ damage manifested by increased liver enzymes or kidney function occur in the progressive or intermediate phase of shock. Tachycardia, rather than bradycardia, occurs in shock states secondary to catecholamines released as compensatory mechanisms.

What are the actions of renin in the maintenance of blood pressure? Select all that apply. 1 Decrease urine output 2 Decrease sodium reabsorption 3 Constrict peripheral blood vessels 4 Stimulate cardiac pump activity 5 Increase blood potassium levels

1. Decrease urine output 3. Constrict peripheral blood vessels Rationale: Renin is produced in the body as a response to low blood pressure. This enzyme helps in maintaining blood pressure by decreasing urine output and constricting peripheral blood vessels. Renin also increases sodium reabsorption in the kidney which causes further retention of water. Renin does not directly affect cardiac function or potassium levels.

Which sign of hypovolemic shock does the nurse instruct the client who had an outpatient surgical procedure to report immediately? 1 Dizziness 2 Lack of appetite 3 Mild pain at the site of the procedure 4 1-cm clear yellow drainage from incision

1. Dizziness Rationale: Dizziness or lightheadedness may indicate hypotension and possible shock. Thirst, rather than anorexia, is a symptom of hypovolemic shock. Mild pain may occur after a surgical procedure, but increases in pain should be reported because this may indicate further bleeding with tissue compression. Obvious bleeding, rather than serous drainage, should be reported to the provider.

The client with which problem is at highest risk for hypovolemic shock? 1 Esophageal varices 2 Kidney failure 3 Arthritis and daily acetaminophen use 4 Kidney stone

1. Esophageal varices Rationale: Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal (GI) bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ibuprofen, not acetaminophen, predispose the client to GI bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss and hypovolemia.

A client has developed hypovolemic shock related to profound ascites and fluid shift. Which laboratory value does the nurse expect to see? 1 Hematocrit 54% 2 Paco2 45 mm Hg 3 Potassium 4.4 mEq/L 4 Lactic acid 2.2 mmol/L

1. Hematocrit 54% Rationale: Shock caused by dehydration or fluid shifts results in increased hemoglobin and hematocrit levels due to hemoconcentration. The Paco2, potassium, and lactic acid values given are within normal limits; they would be increased in the client who is in a shock state.

Which are risk factors for hypovolemic shock? Select all that apply. 1 Hemophilia 2 Malnutrition 3 Diuretic therapy 4 Spinal cord injury 5 Myocardial infarction

1. Hemophilia 2. Malnutrition 3. Diuretic therapy Rationale: Specific risk factors for hypovolemic shock include hemophilia, malnutrition, and diuretic therapy. Hypovolemia can be caused by impaired clotting in clients with hemophilia and malnourishment. Excessive diuresis due to diuretic therapy can also cause reduction in blood volume. Clients with spinal cord injury have distributive shock in which the total blood volume is not reduced but fluid shifts from the central vascular space. In clients with myocardial infarction, cardiac function is impaired which causes cardiogenic shock.

The client with which lab result is at risk for hemorrhagic shock? 1 International Normalized Ratio (INR) 7.9 2 Partial thromboplastin time (PTT) 12.5 seconds 3 Platelets 170,000/mm3 4 Hemoglobin 8.2 g/dL

1. International Normalized Ratio (INR) 7.9 Rationale: Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.

Which are cardiovascular manifestations of hypovolemic shock? Select all that apply. 1 Narrow pulse pressure 2 Postural hypotension 3 Decreased pulse rate 4 Decreased cardiac output 5 Bounding peripheral pulses

1. Narrow pulse pressure 2. Postural hypotension 4. Decreased cardiac output Rationale: In hypovolemic shock, total body fluid is reduced; therefore, the difference between systolic and diastolic pressure (pulse pressure) is decreased. Blood pressure in the body drops also causing postural hypotension. The decrease in blood volume causes a simultaneous decrease in cardiac output. There is a compensatory increase in pulse rate to restore cardiac output in shock. Peripheral pulses become weak in hypovolemic shock.

A client in hypovolemic shock presents with a normal hematocrit and hemoglobin. What type of fluid should the nurse anticipate the healthcare provider will prescribe to restore oncotic pressure? 1 Plasma 2 Whole blood 3 Ringer's lactate 4 Packed red cells

1. Plasma Rationale: The ideal intervention for restoring osmotic pressure in a client with normal hematocrit and hemoglobin is plasma. Plasma protein fractions and synthetic plasma expanders are used to increase fluid volume. Whole blood is suitable for replacing large blood losses in clients with a decrease in hemoglobin and hematocrit levels. Ringer's lactate does not restore oncotic pressure; it is a crystalloid that restores fluid volume and is used in instances where the client needs volume expansion and correction of acidosis. Packed red cells are chosen for moderate blood losses when the client needs red blood cells without added fluid volume.

A 70-year-old client is admitted after a spider bite to the finger 12 hours ago. Which of these assessment data suggest the client has sepsis? Select all that apply. RR 28/min, temp 101.5, HR 116, BP 92/60, lungs CTA, BG 142, WBC 14,500, Hgb 15g/dL, Na 140, K 4.1, AxO, anxious 1 Respiratory rate 2 Blood pressure 3 Breath sounds 4 Serum glucose 5 Anxiety 6 Serum potassium

1. Respiratory rate 2. Blood pressure 4. Serum glucose Rationale: Clients with sepsis present with a cluster of symptom manifestations in response to a systemic infection. Symptoms consistent with inflammation (tachycardia, tachypnea, temperature, white blood cell change) and additional clinical manifestations (hypotension, decreased urine output, positive fluid balance, decreased capillary refill, hyperglycemia, mental status change, increased serum creatinine) are seen in clients with sepsis.

Which conditions are identified as specific causes of distributive shock? Select all that apply. 1 Sepsis 2 Cardiac tamponade 3 Anaphylaxis 4 Capillary leak 5 Pericarditis

1. Sepsis 3 . Anaphylaxis 4 . Capillary leak Rationale:

A client recovering from an open reduction of the femur suddenly feels lightheaded, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? 1 Temperature 2 Pulse 3 Respiration 4 Blood pressure

1. Temperature Rationale: A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.

Which vital sign change in a client with hypovolemic shock indicates to the nurse that the fluid resuscitation therapy is effective? 1 Urine output increase from 5 to 35 mL/hr 2 Heart rate increase from 62 to 76 beats/min 3 Respiratory rate increase from 22 to 26 breaths/min 4 Core body temperature decrease from 98.8° F (37.1° C) to 98.2° F (36.8° C)

1. Urine output increase from 5 to 35 mL/hr Rationale: During shock, the kidneys and baroreceptors sense an ongoing decrease in mean arterial pressure and trigger the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation, which is very sensitive to changes in fluid volume. Renin, secreted by the kidney, causes decreased urine output. ADH increases water reabsorption in the kidney, further reducing urine output. These actions compensate for shock by attempting to prevent further fluid loss. This response is so sensitive that urine output is a very good indicator of fluid resuscitation adequacy. If the therapy is not effective, urine output does not increase. An increase in respiratory rate, increase in heart rate, and a decrease in core body temperature are not expected findings of successful fluid resuscitation.

A client with septic shock is to receive dopamine at 18 mcg/kg/min. The clients weight is 154 pounds. How many mcg/min does the nurse administer? (Chp. 37; elsevier resources)

1260 mcg/min (Chp. 37; elsevier resources)

A client experiencing shock asks the nurse, "What is going to happen to me?" Which response is best for the nurse to convey? 1 "You seem quite anxious. What do you think will happen?" 2 "We are doing everything appropriate for your condition, and I am monitoring you closely." 3 "The shock condition is taking the blood away from your brain. That is why you are anxious." 4 "Your blood pressure is quite low, which happens when you lose a lot of blood."

2. "We are doing everything appropriate for your condition, and I am monitoring you closely." Rationale: The client in shock should be reassured that appropriate treatment is being carried out. Reflecting the client's anxiety back to him or her at this time is not therapeutic, as the client has asked for information. Providing the physiologic rationale for the client's anxiety is not appropriate at this time, nor does it speak to the client's concerns. There is no indication that the client is losing blood, but in a shock state the blood pressure is low; however, this response does not answer the client's concern as to what will happen.

Which client does the nurse consider to be at highest risk for the development of sepsis? 1 75-year-old man with hypertension and early Alzheimer's disease 2 45-year-old woman 2 days postoperative from bowel surgery for treatment of cancer 3 80-year-old community-dwelling man with no other health problems undergoing cataract surgery 4 54-year-old woman with type 2 diabetes mellitus and severe degenerative joint disease of the right knee

2. 45-year-old woman 2 days postoperative from bowel surgery for treatment of cancer Rationale: The 45-year-old woman has several risk factors. First she has cancer which compromises immune function. Bowel surgery is the more significant risk factor for this client, as not only does major surgery further reduce the immune response, but the bowel cannot be "sterilized" for surgery. Therefore the usual bacteria of the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted. The 75-year-old client with hypertension and Alzheimer's disease and the 80-year-old undergoing cataract surgery only have age as a risk factor for sepsis. The 54-year-old with type 2 diabetes and degenerative joint disease is at risk for sepsis due to the diabetes, but this client has no other risk factors.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? 1 Hourly urine output 10-12 mL/hr 2 Blood pressure 90/60 and mean arterial pressure (MAP) 70 3 Blood glucose 245 4 Serum creatinine 3.6 mg/d

2. Blood pressure 90/60 and mean arterial pressure (MAP) 70 Rationale: Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and is a negative consequence of shock, not a positive response. Although a blood glucose of 245 is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? 1 Client receiving a blood transfusion 2 Client with severe ascites 3 Client with myocardial infarction 4 Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

2. Client with severe ascites Rationale: Fluid shifts from vascular to intraabdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess ADH secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? 1 Administer the antibiotic immediately. 2 Ensure that blood cultures were drawn. 3 Obtain signature for informed consent. 4 Take the client's vital signs.

2. Ensure that blood cultures were drawn. Rationale: Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1-3 hours; timing is essential.

A client admitted with a bleeding duodenal ulcer is NPO and has a nasogastric tube in place connected to low continuous suction. What assessment finding does the nurse report to the provider as a possible indicator of nonprogressive stage of shock? 1 Serum potassium level of 4.7 mEq/L 2 Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg 3 Urine output of 30 mL/hour 4 Increased confusion

2. Decrease in mean arterial pressure (MAP) from 76 mm Hg to 62 mm Hg Rationale: When shock progresses from the initial stage to the nonprogressive stage, symptoms are subtle but present. Once the client enters the progressive and refractory stage of shock, manifestations are more obvious and may not be responsive to therapy. Recognizing early manifestations of shock are important to client outcomes. The nonprogressive stage of shock is present when the MAP decreases by 10-15 mm Hg from baseline, urine output decreases, and heart rate and respiratory rate increase. Confusion and moderate hyperkalemia is observed in the progressive stage of shock. The client's urine output is still within normal limits as may be seen in the initial stage of shock, but urine output will continue to decrease as the shock stages progress.

Which finding contributes to an acidotic state in a client with septic shock? 1 Hemoglobin of 12 g/dL 2 Lactate level of 9.2 mmol/L 3 Platelet count of 150,000 cells/mm3 4 Peripheral oxygen saturation of 95%

2. Lactate level of 9.2 mmol/L Rationale: Elevated lactate levels occur with anaerobic metabolism consistent with metabolic acidosis. Hemoglobin of 12 g/dL is within normal range and does not reflect disseminated intravascular coagulation (DIC), which may be found in clients with septic shock. Platelets are low, but may reflect DIC if they drop further, rather than metabolic acidosis. A pulse oximetry reading of 95% is a normal value and does not support hypoxemia or tissue hypoxia.

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? 1 Localized erythema and edema 2 Low-grade fever and mild hypotension 3 Low oxygen saturation rate and decreased cognition 4 Reduced urinary output and an increased respiratory rate

2. Low-grade fever and mild hypotension Rationale: Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and an increased respiratory rate indicate severe sepsis.

A client who underwent a radical colon resection for metastatic cancer has developed septic shock and remains neurologically unresponsive, unable to breathe without mechanical ventilator support, requires dialysis for renal function, is not tolerating tube feedings, and is beginning to show signs of hepatic failure. What condition does the nurse suspect the client has developed based on these clinical manifestations? 1 Late stage of septic shock 2 Multiple organ dysfunction syndrome (MODS) 3 Intercerebral hemorrhage 4 Adverse reaction to sedating agents

2. Multiple organ dysfunction syndrome (MODS) Rationale: Shock that progresses to the refractory stage causes irreversible cell death and tissue damage, releasing toxic metabolites that cause organs to fail. Once the sequence of multiple organs begins to fail because of the buildup of metabolites and toxins, the client's condition is termed multiple organ dysfunction syndrome. MODS involves the presence of altered organ functions in two or more organ systems. In this client, four organs have "failed' with a fifth (the liver) imminent.

Which term best describes the symptoms that occur in the nonprogressive (compensatory) phase of shock? 1 Hypoxemia 2 Oliguria 3 Decreased tissue perfusion 4 Blood loss related to hemorrhage

2. Oliguria Rationale: Compensatory mechanisms in the nonprogressive stage of shock result from increased sympathetic nervous stimulation and release of antidiuretic hormone (ADH); vasoconstriction and water retention to maintain fluid volume occur with oliguria as a result. Problems such as reduction in mean arterial pressure and tissue perfusion, hypoxemia, and acid-base imbalances occur in the compensatory phase, but compensatory mechanisms keep the pulse oximetry reading within 2-5% of baseline. Blood loss may occur in hemorrhagic or hypovolemic shock; this question addresses the overall shock state.

The client in shock has the following vital signs: T 99.8° F, P 132, R 32, and BP 80/58. Calculate the pulse pressure and record as a whole number.

22 Rationale: Pulse pressure is the difference between the systolic and diastolic pressures. 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)

The client in shock has the following vital signs: T 99.8° F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure. (Chp. 37; elsevier resources)

22 mmHg (Chp. 37; elsevier resources)

A client in hypovolemic shock has been placed on an infusion of the vasopressor agent norepinephrine (Levophed). Which parameter indicates a desired client response to the therapy? 1 Heart rate change from 112 to 123 beats/min 2 Decreased peripheral pulses 3 Mean arterial pressure change from 66 to 78 mm Hg 4 Urine output remains at 30 mL/hour

3. Mean arterial pressure change from 66 to 78 mm Hg Rationale: If fluid therapy is not effective in increasing blood pressure, vasoconstricting drugs may be added to increase tissue perfusion. When vasoactive agents are administered, the nurse monitors for effectiveness by evaluating improvements in cardiac output and mean arterial pressure. An increase, not decrease, in urine output is a desired response. An increased heart rate is expected due to sympathetic nervous system stimulation of norepinephrine. Decreased peripheral pulses may occur due to vasoconstrictor effects, but it is not a desired response.

A client is scheduled for thoracotomy later today. Which entry noted on the medication reconciliation record poses a risk for perioperative hemorrhagic shock and causes the nurse to contact the provider immediately? 1 Captopril (Catapres) 2 Furosemide (Lasix) 3 Naproxen (Naprosyn) 4 Omeprazole (Prilosec)

3. Naproxen (Naprosyn) Rationale: Naproxen is a nonsteroidal antiinflammatory agent that poses a risk for bleeding. Captopril (for hypertension), furosemide (for heart failure), or omeprazole (prevents gastroesophageal reflux disease and gastrointestinal bleeding from stomach ulcers) do not pose risks for bleeding. Anticoagulants, aspirin, and NSAIDs should be questioned.

What typical sign/symptom indicates the early stage of septic shock? 1 Pallor and cool skin 2 Blood pressure 84/50 mm Hg 3 Tachypnea and tachycardia 4 Respiratory acidosis

3. Tachypnea and tachycardia Rationale: Signs of systemic inflammatory response syndrome, which precede sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.

Which problem places a client at highest risk for septic shock? 1 Kidney failure 2 Cirrhosis 3 Lung cancer 4 40% burn injury

4. 40% burn injury Rationale: The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.

A client admitted with pneumonia and possible sepsis has a blood pressure of 90/46 mm Hg, heart rate of 128 beats/min, respiratory rate of 28/min, temperature of 38.5° C, no urine output for 4 hours, and central venous pressure of 2 mm Hg. The client arouses to name but is not oriented. Which order does the nurse implement first? 1 Obtain blood cultures. 2 Insert an indwelling urinary catheter. 3 Apply a cooling blanket. 4 Administer 500 mL intravenous colloid bolus over 30 minutes.

4. Administer 500 mL intravenous colloid bolus over 30 minutes. Rationale: A resuscitation bundle is used for the treatment of sepsis. While several interventions are part of a bundle, the nurse prioritizes the interventions based on the assessment of the client. Establishing perfusion is a priority with this client, thus starting the IV fluid bolus should be the first priority in care. Obtaining blood cultures, especially prior to administering antibiotics, is also important along with placing an indwelling urinary catheter to monitor the client's response to fluid therapy. A cooling blanket is not part of the bundle and may not be an appropriate intervention.

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? 1 Obtain IV access and hang prescribed fluid infusions. 2 Apply the automatic blood pressure cuff. 3 Assess level of consciousness and pupil reaction to light. 4 Check the airway and respiratory status.

4. Check the airway and respiratory status. Rationale: When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

A client in the progressive or intermediate stage of hypovolemic shock will exhibit which manifestation? 1 Polyuria 2 Metabolic alkalosis 3 Moist, warm skin 4 Feeling of impending doom

4. Feeling of impending doom Rationale: As shock progresses, tissue perfusion to the brain continues to be reduced, causing a sense of anxiety or that "something bad" is about to happen. Oliguria or anuria occurs in the nonprogressive stage rather than polyuria. A lack of perfusion to the skin results in cool, moist skin rather than warm skin. Due to decreased tissue perfusion, buildup of lactic or metabolic acid occurs; the arterial blood gases reflect metabolic acidosis at this time.

The nurse is preparing to administer a transfusion of packed red blood cells to a client with hemorrhagic shock. Which action is essential before initiating the transfusion? 1 Check the volume of blood in the bag. 2 Monitor the client for dark-colored urine. 3 Measure the client's blood pressure. 4 Initiate 0.9% saline solution infusion.

4. Initiate 0.9% saline solution infusion. Rationale: Isotonic solutions such as Ringer's lactate or normal saline may be used as volume expanders in hypovolemic shock. Red blood cells must be given with 0.9% saline to prevent clotting during infusion. While the volume of the blood in the bag is approximately 250 mL, it may vary; however, this is not essential to validate before initiating the transfusion. The nurse monitors for dark urine when an ABO transfusion reaction is suspected. Vital signs, especially a baseline temperature, are indicated prior to transfusion; a low blood pressure during shock states is expected.

Which type of shock is often caused by pulmonary embolism? 1 Hypovolemic shock 2 Cardiogenic shock 3 Distributive shock 4 Obstructive shock

4. Obstructive shock Rationale: Pulmonary embolism can cause obstructive shock by blocking the circulation of blood in the lungs and heart, thus reducing overall cardiac output. Total body fluid is not affected, but central volume is decreased. Hypovolemic shock is characterized by a marked reduction in total blood volume. Cardiogenic shock is caused by failure of the heart to pump blood. Distributive shock is caused by a shift of blood from the vascular spaces to interstitial spaces. Pulmonary embolism does not directly affect total blood volume, myocardial function, or fluid levels in vascular and interstitial spaces.

A client with which problem or condition is at highest risk for septic shock? 1 Obese 2 Post-uncomplicated appendectomy 3 Post-myocardial infarction 4 On prednisone (Deltasone) therapy for rheumatoid arthritis

4. On prednisone (Deltasone) therapy for rheumatoid arthritis Rationale: Clients who do not have intact immune systems are at highest risk for sepsis and septic shock including those who have had organ transplants, with HIV/AIDS, kidney or liver disease, the very old, and those with invasive lines and procedures. Prednisone, taken for autoimmune diseases such as rheumatoid arthritis, suppresses the immune system and prevents further damage to the joints. While obesity, surgery, and hospitalization for MI pose some risk for infection and sepsis, the use of corticosteroid medications is an actual risk for the development of sepsis and septic shock.

Which vasodilator drug is often helpful in managing hypovolemic shock? 1 Milrinone (Primacor) 2 Dobutamine (Dobutrex) 3 Phenylephrine HCl 4 Sodium nitroprusside (Nitropress)

4. Sodium nitroprusside (Nitropress) Rationale: Sodium nitroprusside dilates the coronary arteries, enhancing myocardial perfusion and improving hypovolemic shock. Milrinone and dobutamine are both inotropic agents that act by increasing the force of heart muscle contractions. Phenylephrine is vasoconstrictor, not a vasodilator.

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? 1 Hypotension 2 Bradypnea 3 Heart blocks 4 Tachycardia

4. Tachycardia Rationale: Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.

Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? 1 The LPN/LVN who has 20 years of experience 2 The new RN who recently finished orienting and is working independently with moderately complex clients 3 The RN who will also be caring for a client who had coronary artery bypass grafting (CABG) 12 hours ago 4 The RN with 2 years of experience in intensive care

4. The RN with 2 years of experience in intensive care Rationale: The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. The client who is experiencing septic shock is too complex for the new RN. Although the RN is experienced, this assignment will put the post-CABG client at risk for MRSA infection.

Why are the clinical signs and symptoms of most types of shock the same, regardless of what condition caused the shock to occur? 1 An increase in heart rate is always the first physiologic adjustment the body makes to all stress states. 2 Because blood loss occurs with all types of shock, the most common first clinical symptom is hypotension. 3 Every type of shock interferes with cellular oxygenation in the same sequence. 4 The sympathetic nervous system is triggered by any type of shock and initiates the stress response.

4. The sympathetic nervous system is triggered by any type of shock and initiates the stress response. Rationale: Most manifestations of shock are similar regardless of what starts the process or which tissues are affected first. These common manifestations result from physiologic adjustments (compensatory mechanisms) in an attempt to ensure continued oxygenation of vital organs. These adjustment actions are performed by the sympathetic nervous system triggering the stress response and activating the endocrine and cardiovascular systems.

Shock definition

A condition rather than a disease that is widespread abnormal cellular metabolism that occurs when oxygenation and tissue perfusion needs are not met to the level necessary to maintain cell function. "whole body" response that occurs when too little oxygen is delivered to the tissues. More than one type of shock can be present at the same time.

A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. A) Ask family members to stay with the client. B) Call the health care provider. C) Increase IV and oxygen rates. D) Remain with the client. E) Reassure the client that everything is being done for him or her. (Chp. 37; elsevier resources)

A) Ask family members to stay with the client. D) Remain with the client. E) Reassure the client that everything is being done for him or her. (Chp. 37; elsevier resources)

A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? A) Broad-spectrum antibiotics B) Blood transfusion C) Cooling baths D) NPO status (Chp. 37; elsevier resources)

A) Broad-spectrum antibiotics (Chp. 37; elsevier resources)

The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? A) Compare these vital signs with the last several readings. B) Request that the surgeon see the client. C) Increase the rate of intravenous fluids. D) Reassess vital signs using different equipment. (Chp. 37; elsevier resources)

A) Compare these vital signs with the last several readings. (Chp. 37; elsevier resources)

The client with which problem is at highest risk for hypovolemic shock? A) Esophageal varices B) Kidney failure C) Arthritis and daily acetaminophen use D) Kidney stone (Chp. 37; elsevier resources)

A) Esophageal varices (Chp. 37; elsevier resources)

The client with which laboratory result is at risk for hemorrhagic shock? A) International normalized ratio (INR) 7.9 B) Partial thromboplastin time (PTT) 12.5 seconds C) Platelets 170,000/mm3 D) Hemoglobin 8.2 g/dL (Chp. 37; elsevier resources)

A) International normalized ratio (INR) 7.9 (Chp. 37; elsevier resources)

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Physical Assessment Findings: Pulse 140 beats/min and thready Blood pressure 60/40 mm Hg Respirations 40/min and shallow Diagnostic Findings: ABG respiratory acidosis Lactate level 7 mOsm/L All of these provider prescriptions are given for the client. Which does the nurse carry out first? A) Notify anesthesia for endotracheal intubation. B) Give Plasmanate 1 unit now. C) Give normal saline solution 250 mL/hr. D) Type and crossmatch for 4 units of packed red blood cells (PRBCs). (Chp. 37; elsevier resources)

A) Notify anesthesia for endotracheal intubation. (Chp. 37; elsevier resources)

A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? A) Temperature B) Pulse C) Respiration D) Blood pressure (Chp. 37; elsevier resources)

A) Temperature (Chp. 37; elsevier resources)

Which clients are at immediate risk for hypovolemic shock? Select all that apply. A) Unrestrained client in motor vehicle accident B) Construction worker C) Athlete D) Surgical intensive care client E) 85-year-old with gastrointestinal virus (Chp. 37; elsevier resources)

A) Unrestrained client in motor vehicle accident D) Surgical intensive care client E) 85-year-old with gastrointestinal virus (Chp. 37; elsevier resources)

What body organs are affected by shock:

All body organs, and either work harder to adapt and compensate for reduced oxygenation or fail to function b/c of hypoxia.

A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? A) Hourly urine output 10 to 12 mL/hr B) Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg C) Blood glucose 245 mg/dL D) Serum creatinine 3.6 mg/dL (Chp. 37; elsevier resources)

B) Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg (Chp. 37; elsevier resources)

Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? A) Client receiving a blood transfusion B) Client with severe ascites C) Client with myocardial infarction D) Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion (Chp. 37; elsevier resources)

B) Client with severe ascites (Chp. 37; elsevier resources)

Which laboratory result is seen in late sepsis? A) Decreased serum lactate B) Decreased segmented neutrophil count C) Increased numbers of monocytes D) Increased platelet count (Chp. 37; elsevier resources)

B) Decreased segmented neutrophil count (Chp. 37; elsevier resources)

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? A) Administer the antibiotic immediately. B) Ensure that blood cultures were drawn. C) Obtain signature for informed consent. D) Take the client's vital signs. (Chp. 37; elsevier resources)

B) Ensure that blood cultures were drawn. (Chp. 37; elsevier resources)

How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? A) PaCO2 58 mm Hg B) Lactate 9.0 mmol/L C) Partial thromboplastin time 64 seconds D) Potassium 2.8 mEq/L (Chp. 37; elsevier resources)

B) Lactate 9.0 mmol/L (Chp. 37; elsevier resources)

Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? A) Localized erythema and edema B) Low-grade fever and mild hypotension C) Low oxygen saturation rate and decreased cognition D) Reduced urinary output and increased respiratory rate (Chp. 37; elsevier resources)

B) Low-grade fever and mild hypotension (Chp. 37; elsevier resources)

How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? A) Urine output 20 to 30 mL/hr for the last 4 hours B) Mean arterial pressure (MAP) 70 mm Hg C) Albumin 3.5 g/dL D) Hemoglobin 7.6 g/dL (Chp. 37; elsevier resources)

B) Mean arterial pressure (MAP) 70 mm Hg (Chp. 37; elsevier resources)

A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? A) Obtain vital signs every 15 minutes. B) Measure hourly urine output. C) Check oxygen saturation. D) Assess level of alertness. (Chp. 37; elsevier resources)

B) Measure hourly urine output. (Chp. 37; elsevier resources)

Which change in laboratory value or clinical manifestations in a client with hypovolemic shock indicates to the nurse that current therapy may need to be changed? A) Urine output increases from 5mL/hour to 6mL/hour B) Pulse pressure decreases from 28 mm Hg to 22 mm Hg C) Serum potassium level increases from 3.6 mEq/L to 3.9mEq/L D) Core body temperature increases from 98.2ºF (36.8ºC) to 98.8ºF (37.1ºC) (Chp. 37; p. 749)

B) Pulse pressure decreases from 28 mm Hg to 22 mm Hg (Chp. 37; p. 749)

Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume? A) Edema and weight gain B) Confusion and lethargy C) Decreased urine output and thirst D) Increased pulse and respiratory rates (Chp. 37; p. 746)

C) Decreased urine output and thirst (Chp. 37; p. 746)

The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? A) Admission to rehabilitation hospital for ambulatory retraining B) Collaboration with home care agency for return to home C) Discussion with family and provider regarding palliative care D) Enrollment in a cardiac transplantation program (Chp. 37; elsevier resources)

C) Discussion with family and provider regarding palliative care (Chp. 37; elsevier resources)

Which problem places a client at highest risk for sepsis? A) Pernicious anemia B) Pericarditis C) Post kidney transplant D) Client owns an iguana (Chp. 37; elsevier resources)

C) Post kidney transplant (Chp. 37; elsevier resources)

What typical sign/symptom indicates the early stage of septic shock? A) Pallor and cool skin B) Blood pressure 84/50 mm Hg C) Tachypnea and tachycardia D) Respiratory acidosis (Chp. 37; elsevier resources)

C) Tachypnea and tachycardia (Chp. 37; elsevier resources)

Most often shock is a result of:

Cardiovascular problems & changes.

Obstructive shock:

Caused by problems that impair the ability of the normal heart muscle to pump effectively. Cardiac function decreased by Non-Cardiac factor (indirect pump failure) Total body fluid is not affected alto central volume is decreased

Which problem places a person at highest risk for septic shock? A) Kidney failure B) Cirrhosis C) Lung cancer D) 40% burn injury (Chp. 37; elsevier resources)

D) 40% burn injury (Chp. 37; elsevier resources)

A client with hypovolemic shock has these vital signs: temperature 97.9° F; pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24 breaths/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which medication order for this client does the nurse question? A) Dopamine (Intropin) 12 mcg/kg/min B) Dobutamine (Dobutrex) 5 mcg/kg/min C) Plasmanate 1 unit D) Bumetanide (Bumex) 1 mg IV (Chp. 37; elsevier resources)

D) Bumetanide (Bumex) 1 mg IV (Chp. 37; elsevier resources)

When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? A) Obtain IV access and hang prescribed fluid infusions. B) Apply the automatic blood pressure cuff. C) Assess level of consciousness and pupil reaction to light. D) Check the airway and respiratory status. (Chp. 37; elsevier resources)

D) Check the airway and respiratory status. (Chp. 37; elsevier resources)

Which clinical manifestation in a client alerts the nurse to the probability of septic shock instead of hypovolemic shock? A) Hypotension B) Pale, clammy skin C) Decreased urine output D) Oozing of blood at the IV site (Chp. 37; p.753)

D) Oozing of blood at the IV site (Chp. 37; p. 753)

The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? A) Hypotension B) Bradypnea C) Heart blocks D) Tachycardia (Chp. 37; elsevier resources)

D) Tachycardia (Chp. 37; elsevier resources)

Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? A) The LPN/LVN who has 20 years of experience B) The new RN who recently finished orienting and is working independently with moderately complex clients C) The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago D) The RN with 2 years of experience in intensive care (Chp. 37; elsevier resources)

D) The RN with 2 years of experience in intensive care (Chp. 37; elsevier resources)

Shock can occur:

In any setting: acute care settings are higher risk, but older pt. in long-term care settings are at risk for sepsis and shock related to UTIs.

Hypovolemic Shock: Patho

Loss of blood volume from the vascular space, resulting in a decreased MAP, and a loss of oxygen-carrying capacity from the loss of circulating RBCs. Reduced MAP slows blood flow, resulting in decreased tissue perfusion.

Distributive shock:

Occurs when blood volume is not lost from the body but is distrusted to the interstitial tissues where it cannot circulate and deliver oxygen. Fluid shift from central vascular space (total body fluid volume normal or increased).

Chemical-induced distributive shock:

Occurs when certain body chemicals or foreign substances in the blood and vessels start widespread changes in blood vessel walls. 3 common origins: sepsis, anaphylaxis, cap leak syndrome.

Cardiogenic shock:

Occurs when the actual heart muscle is unhealthy & pumping is directly impaired. Direct pump failure (fluid volume not affected)

Septic shock:

When sepsis leads to distributive shock b/c of infectious microorganisms are present in the blood. * stage of sepsis and SIRS when multiple organ failure is evident and uncontrolled bleeding occurs * death rate exceeds 50%

Sepsis:

Widespread infection that triggers a whole-body inflammatory response.

Why is shock considered a syndrome?

b/c cellular tissue, and organ events occur in a predictable sequence.