Chapter 14: Shock and Multiple Organ Dysfunction Syndrome (Suddarth)
22. The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply. A) Drop in systolic blood pressure of 40 mm Hg from baselines B) Hypotension that responds to bolus fluid resuscitation C) Exaggerated response to vasoactive medications D) Serum lactate >4 mmol/L E) Mean arterial pressure (MAP) of 65 mm Hg
ADE ( Feedback: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure)
4. The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock? A) Lactated Ringers B) Albumin C) Dextran D) 3% NaCl
A ( Feedback: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringers and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. 3% NaCl is a hypertonic solution and is not isotonic.)
2. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. B) There is an uncontrolled increase in cardiac output. C) Blood pressure regulation becomes irregular. D) The patient experiences tachycardia and a bounding pulse.
A ( Feedback: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.)
15. The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion? A) The patient is in the compensatory stage of shock. B) The patient is in the progressive stage of shock. C) The patient will stabilize and be released by tomorrow. D) The patient is in the irreversible stage of shock.
A ( Feedback: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patients chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.)
13. You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient? A) Hypothermia B) Bradycardia C) Coffee ground emesis D) Pain
A ( Feedback: Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the patient for cardiovascular overload and pulmonary edema when large volumes of IV solution are administered. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.)
14. The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions
A ( Feedback: When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts drip rates based on the prescribed dose and the patients response. Reviewing medications, performing a focused cardiovascular assessment, and providing patient education are important nursing tasks, but they are not specific to the administration of IV vasoactive drugs. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema are not the priorities for administration of IV vasoactive drugs. Vital signs are taken on a frequent basis when monitoring administration of IV vasoactive drugs, vasoactive medications should be administered through a central venous line, and early discharge instructions would be inappropriate in this time of crisis.)
16. The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A) Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock. B) Inform the patients family immediately that the patient will likely not survive to allow the family time to make plans and move forward. C) Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life. D) Protect the patients airway, optimize intravascular volume, and initiate the early rehabilitation process.
A (Feedback: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patients family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues.)
19. The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patients heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? A) Dysrhythmias B) Increase in blood pressure C) Increase in heart rate D) Decrease in oxygen demands
A ( Feedback: Cardiogenic shock occurs when the hearts ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not cause increased blood pressure, increased heart rate, or a decrease in oxygen demands.)
6. A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? A) Anaphylactic shock B) Neurogenic shock C) Septic shock D) Hypovolemic shock
B ( Feedback: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.)
8. The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention? A) Reviewing the cause of shock and prioritizing the patients psychosocial needs B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C) Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive D) Promoting the patients coping skills in an effort to better deal with the physiologic changes accompanying shock
B ( Feedback: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.)
18. The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patients elevated energy requirements during prolonged rehabilitation? A) Loss of adipose tissue B) Loss of skeletal muscle C) Inability to convert adipose tissue to energy D) Inability to maintain normal body mass
B ( Feedback: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patients recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this patient.)
1. A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
B ( Feedback: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.)
5. A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurses care planning during the administration of a vasoactive drug? A) The drug should be discontinued immediately after blood pressure increases. B) The drug dose should be tapered down once vital signs improve. C) The patient should have arterial blood gases drawn every 10 minutes during treatment. D) The infusion rate should be titrated according the patients subjective sensation of adequate perfusion.
B ( Feedback: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every10-minute draws are not the norm.)
12. The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock? A) Elevated systolic blood pressure B) Elevated mean arterial pressure (MAP) C) Shallow, rapid respirations D) Bradycardia
C ( Feedback: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.)
11. The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? A) Increased hunger B) Decreased thirst C) Decreased urinary output D) Increased capillary perfusion
C ( Feedback: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.)
7. The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patients nutritional needs. What physiologic process contributes to these increased nutritional needs? A) The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP) B) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements D) The increase in GI peristalsis during shock and the resulting diarrhea
C ( Feedback: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.)
10. The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurses plan of care should include which of the following interventions? A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
C ( Feedback: Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patients wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.)
17. The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this patient is what? A) 5% albumin because it is inexpensive and is always readily available B) Dextran because it increases intravascular volume and counteracts coagulopathy C) Whatever fluid is most readily available in the clinic, due to the nature of the emergency D) Lactated Ringers solution because it increases volume, buffers acidosis, and is the best choice for patients with liver failure
C ( Feedback: The best fluid to treat shock remains controversial. In emergencies, the best fluid is often the fluid that is readily available. Fluid resuscitation should be initiated early in shock to maximize intravascular volume. Both crystalloids and colloids can be administered to restore intravascular volume. There is no consensus regarding whether crystalloids or colloids, such as dextran and albumin, should be used; however, with crystalloids, more fluid is necessary to restore intravascular volume. Albumin is very expensive and is a blood product so it is not always readily available for use. Dextran does increase intravascular volume, but it increases the risk for coagulopathy. Lactated Ringers is a good solution choice because it increases volume and buffers acidosis, but it should not be used in patients with liver failure because the liver is unable to covert lactate to bicarbonate.)
21. The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states? A) Third spacing of fluid B) Dysrhythmias C) Tachycardia D) Gastric hypermotility
C (Feedback: Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.)
20. The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient? A) It promotes coping and slows catecholamine release. B) It stimulates the patient so he or she is more alert. C) It decreases gastric secretions. D) It dilates the blood vessels.
D ( Feedback: For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patients anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions. )
3. The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin
D ( Feedback: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patients skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.stages of shock)
9. When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? A) Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
D ( Feedback: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.)