Shock

A patient is in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse? "We have specific visiting hours that must be adhered to." "I will make arrangements for your family to be able to stay with the patient." "The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area." "You don't want to remember your family member this way."

"The healthcare team needs room to do procedures to help your family member, so it would be best if you stayed in the waiting area."

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) A heart rate >100 bpm Respirations <15 breaths/min Compensatory respiratory acidosis Lethargy and mental confusion Crackles

A heart rate >100 bpm Crackles Lethargy and mental confusion

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is An older adult man with end-stage renal disease and an infected dialysis access site A young female adolescent who developed shock from tampon use during menses An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection A middle-aged woman with metastatic breast cancer and a BMI of 26

An older adult man with end-stage renal disease and an infected dialysis access site

A client is experiencing severe anaphylactic shock. What actions should the nurse take first? Select all that apply. Ask the client if they are lightheaded. Administer diphenhydramine. Prepare for insertion of an endotracheal tube. Check for hematuria. Give intravenous fluids. Give metoprolol.

Ask the client if they are lightheaded. Administer diphenhydramine. Give intravenous fluids. Prepare for insertion of an endotracheal tube.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. Trauma Diarrhea Dehydration Burns Vomiting

Burns Dehydration

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse Begins the enteral nutritional supplement at 100 mL/hr to ensure adequate calories Measures the nasogastric tube from earlobe to xiphoid process and marks the tube with tape at this level Consults with the physician about substituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix) Obtains consent by a family member for placement of a percutaneous endoscopic gastrostomy (PEG) tube

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

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? Abdominal pain unresponsive to analgesics Increased abdominal girth accompanied by decreased level of consciousness Sudden increase in random blood glucose readings Fever, increased heart rate and decreased blood pressure

Fever, increased heart rate and decreased blood pressure

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. Hypothermia Venous pooling Hypotension Tachypnea Tachycardia Diaphoresis

Hypotension Venous pooling Tachypnea Hypothermia

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Loss in consciousness Decreases in liver enzymes Ecchymoses and petechiae Reports of chest pain Increased paCO² levels

Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in which organ? Lungs Kidneys Brain Liver

Lungs

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. Maintain a patent airway. Raise the head of the bed 30 degrees. Apply a warming blanket. Administer blood products per orders. Apply oxygen per orders. Frequently monitor neurological status.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure? Rapid, shallow respirations Lethargy and confusion Respiratory alkalosis Myocardial depression

Myocardial depression

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? Shock Pancreatic necrosis Tetany MODS

Pancreatic necrosis

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention? Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea Promoting communication with the client and family along with addressing end-of-life issues

Promoting communication with the client and family along with addressing end-of-life issues

The ICU nurse is caring for a client with multiple organ dysfunction syndrome (MODS) due to shock. What nursing action should be prioritized at this point during care? Preparing the family for a long recovery process Educating the client regarding the use of supportive fluids Facilitating the rehabilitation phase of treatment Providing information and support to family members

Providing information and support to family members

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? Respiratory pattern Numbness and tingling Pain level Pulse and blood pressure

Pulse and blood pressure

Which of the following are the immediate complications of spinal cord injury? Tetraplegia Respiratory arrest Autonomic dysreflexia Spinal shock Paraplegia

Respiratory arrest Spinal shock

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. The client who reports an allergy to peanuts that causes throat swelling The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55 year-old client with spina bifida The client with an infection who is prescribed intravenous vancomycin The client who is scheduled for a repeat CT scan of the abdomen

The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55 year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling

Clinical manifestations of neurogenic shock include which of the following? Select all that apply. Bradycardia Tachycardia Profuse bilateral sweating Venous pooling in the extremities Warm skin

Venous pooling in the extremities Bradycardia Warm skin

The nurse in a rural nursing outpost will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. What principle should guide the nurse's administration of intravenous fluid? Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency Lactated Ringer's solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure 5% albumin is preferred because it is inexpensive and is always readily available Dextran should be given because it increases intravascular volume and counteracts coagulopathy

Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency

Which are possible long-term complications of spinal cord injury? Select all that apply. autonomic dysreflexia respiratory infection areflexia respiratory arrest

autonomic dysreflexia respiratory infection

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. dobutamine nitroprusside dopamine nitroglycerin epinephrine

dobutamine dopamine epinephrine

A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? bradycardia constipation low urine output rapid respirations

low urine output

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply. epinephrine phenylephrine norepinephrine vasopressin milrinone

norepinephrine epinephrine vasopressin phenylephrine

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. administer pantoprazole IV daily monitor urine output every hour institute vital signs every 4 hours obtain a urine specimen for culture maintain the IV site inserted on admission

obtain a urine specimen for culture administer pantoprazole IV daily monitor urine output every hour