Shock (ch 11)

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

100% oxygen via a nonrebreather mask

The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?

"A pulmonary artery pressure provides information about pressure on the left side of the heart."

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order?

"Infuse I.V. fluids at 83 ml/hour."

A client is believed to be 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?

"The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them."

Hypovolemic shock is characterized by decreased intravascular volume. The nurse understands that shock would occur if the intravascular volume decreased by 15% to 25%. Therefore, for a 70 kg adult, hypovolemic shock would occur with a minimum intravascular volume of:

3 to 5.1 L.

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?

300 mL

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing?

neurogenic

Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply.

Acid-base imbalance, Increased capillary permeability and fluid and electrolyte shifts, Increased blood urea nitrogen and serum creatinine

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement?

Administer norepinephrine as prescribed.

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? - Stress ulcer - Disseminated intravascular coagulation (DIC) - Septicemia - Stevens-Johnson syndrome from the administration of antibiotics

Disseminated intravascular coagulation (DIC)

Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: - Blood pressure - Breath sounds. - Renal output. - Heart rate.

Blood pressure.

What is the consequence of the release of catecholamines in the skeletal muscles during the compensation stage of shock?

Blood supply to the skeletal muscles increases.

The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:

Cold, clammy skin and tachycardia.

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Decompensation

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is

Dextran

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?

Irreversible

A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock?

HR, 48 bpm; BP, 90/60 mm Hg

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

Identify the cause of shock, administer intravenous fluids, Monitor for changes in vital signs.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?

Increase in arterial oxygenation

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? - Slow the heart rate - Increase the force of myocardial contraction - Depress the central nervous system - Dilate the bronchial tree

Increase the force of myocardial contraction

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

Lansoprazole, Nizatidine, Famotidine (Pepcid)

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first

Lays the client flat with the feet elevated

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

Levophed

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

Lung sounds

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

Neurogenic

Which vasodilator medication is used in the treatment of shock?

Nitroglycerin

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart?

Nitroprusside

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart?

Nitroprusside

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

Oxygen at 2 L/min by nasal cannula

Clinical characteristics of neurogenic shock are noted by which type of stimulation?

Parasympathetic

The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?

Progressive

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock?

Progressive

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg?

Progressive

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?

Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock.

A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse

Raises the foot of the client's bed

The nurse is caring for a client in the compensation stage of shock. One of the body's mechanisms of compensation in this stage of shock is the action of the renin-angiotensin-aldosterone system. What does this system do?

Restores blood pressure

The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines?

Sodium and glucose levels

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as

Sodium nitroprusside

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

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock?

The client with testicular cancer who is receiving intravenous chemotherapy

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

The difference between the systolic and diastolic pressure

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding.

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?- Insert indwelling catheters for incontinent patients. - Use strict hand hygiene techniques. - Administer prophylactic antibiotics for all patients at risk. - Have patients wear masks in the health care facility.

Use strict hand hygiene techniques.

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

Vital signs, Skin color, Urine output, Peripheral pulses

A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply.

antacids, H2 blockers, proton pump inhibitors

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply.

kidney failure, disseminated intravascular coagulation, acute respiratory distress syndrome

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

cardiogenic shock

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit?

compensatory respiratory alkalosis

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?

low urine output

A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?

distributive

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, dopamine, epinephrine

A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply.

heart fails as effective pump, blood volume decreases, peripheral vascular dilation