Chapter 17: Shock

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 A mean arterial blood pressure of 70 mm Hg Bradycardia with a heart rate of 60 beats/min

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

What is the major clinical use of dobutamine? increase cardiac output. prevent sinus bradycardia. treat hypotension. treat hypertension. TAKE ANOTHER QUIZ

increase cardiac output.

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 40% 50% 60% 70%

70%

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: Valvular damage. Cardiomyopathies. A myocardial infarction. Arrhythmias.

A myocardial infarction

Which colloid is expensive but rapidly expands plasma volume? Albumin Dextran Lactated Ringer solution Hypertonic saline

Albumin

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? Albumin Dextran Lactated Ringer solution Hypertonic saline

Albumin

Which type of shock occurs from an antigen-antibody response? Septic Anaphylactic Neurogenic Cardiogenic

Anaphylactic

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.

Older adults with impaired cardiac function are more likely to develop which type of shock? Cardiogenic shock Neurogenic shock Septic shock Anaphylactic shock

Cardiogenic shock

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 systolic blood pressure of 75 mm Hg. A heart rate of 140. Crackles and shallow breathing.

Cold, clammy skin and tachycardia.

A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care? Communicate clearly and frequently with the client's family. Taper down interventions slowly when the prognosis worsens. Transfer the client to a subacute unit when recovery appears unlikely. Ask the client's family how they would prefer treatment to proceed.

Communicate clearly and frequently with the client's family.

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? Initial stage Compensatory stage Progressive stage Irreversible stage

Compensatory stage

The emergency nurse is admitting a client 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? Increased urine output Decreased heart rate Hyperactive bowel sounds Cool, clammy skin

Cool, clammy skin

The acute care nurse is providing care for an adult client 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 antidiuretic hormone during hypovolemic shock? Increased hunger Decreased thirst Decreased urinary output Increased capillary perfusion

Decreased urinary output

A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply. Hypovolemia Difficulty breathing Cardiovascular overload Pulmonary edema Hypoglycemia

Difficulty breathing Cardiovascular overload Pulmonary edema

Which of the following nursing interventions helps minimize the risk for hypothermia in a patient in shock? Direct warming lights to the patient's body Administer prescribed adrenergic and bronchodilating drugs Administer prescribed antipyretics Administer a tepid sponge bath

Direct warming lights to the patient's body

A client has been admitted to the ICU after a MVA. Which nursing interventions will help minimize this client's risk for developing hypothermia as a result of shock? Select all that apply. Direct warming lights to the client's body. Keep the client's head covered with a turban. Administer prescribed adrenergic drugs. Administer prescribed antipyretics.

Direct warming lights to the patient's body Keep the client's head covered with a turban

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)

The ICU nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring? Urinary output increases Skin becomes warm and dry Adventitious lung sounds occur in the upper airway Heart and respiratory rates are elevated

Heart and respiratory rates are elevated

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? Fluid volume circulating in the blood vessels decreases. There is an uncontrolled increase in cardiac output. Blood pressure regulation becomes irregular. The client experiences tachycardia and a bounding pulse.

FLuid volume circulating in the blood vessels decreases.

The nurse is caring for a client in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. What assessments and interventions should the nurse prioritize? Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration Reviewing medications, performing a focused cardiovascular assessment, and providing client education Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge instructions

Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration

The nurse is caring for a client admitted with cardiogenic shock. The client 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 client? It promotes coping and slows catecholamine release. It stimulates the client so he or she is more alert. It decreases gastric secretions. It dilates the blood vessels.

It dilates the blood vessels.

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? 0.9% sodium chloride Lactated Ringer's Albumin Dextran

Lactated Ringer's

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer? Lactated Ringer's Albumin Dextran 3% NaCl

Lactated Ringer's

The nurse is caring for a patient in liver failure who is exhibiting signs and symptoms of hypovolemic shock. The nurse should anticipate that the health care provider will order the administration of what crystalloid for the management of this patient? Lactated Ringer's Albumin Dextran 3% NaCl

Lactated Ringer's

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 Dobutrex Nipride Methotrexate

Levophed

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the brain. lungs. liver. kidneys.

Lungs

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? Absence of infarcts or emboli Reduced stroke volume and cardiac output Absence of pulmonary and peripheral edema Maintenance of adequate mean arterial pressure

Maintenance of adequate mean arterial pressure

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? Codeine Meperidine Hydromorphone Morphine

Morphine

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. Inform the client's family immediately that the client will likely not survive to allow the family time to make plans and move forward. Closely monitor fluid replacement therapy, and inform the family that the client will probably survive and return to normal life. Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process.

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

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? Providing information and support to family members 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

A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boy's mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock? Rapid onset of acute hypertension Rapid onset of respiratory distress Rapid onset of neurologic compensation Rapid onset of cardiac arrest

Rapid onset of respiratory distress

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Pericardiocentesis Thoracotomy with chest tube insertion Administration of oxygen via venture mask Intubation and mechanical ventilation

intubation and mechanical ventilaion

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock? Apply an antibiotic ointment to the client's mucous membranes, as prescribed. Perform passive range-of-motion exercises unless contraindicated Initiate total parenteral nutrition (TPN) Remove invasive devices as soon as they are no longer needed

Remove invasive devices as soon as they are no longer needed

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Septic Anaphylactic Neurogenic Cardiogenic

Septic

A client who has been brought to the ED is unresponsive and has recently shown symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. The client's labs show an elevated WBC; cultures are forthcoming. Why is time of the essence in treating this client's condition? Septic shock is the deadliest form of shock Anaphylactic shock is the deadliest form of shock Neurogenic shock is the deadliest form of shock Cardiogenic shock is the deadliest form of shock

Septic shock is the deadliest form of shock

The nurse is providing care for a client 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 compensatory mechanism will increase the client's cardiac output during the hypovolemic state? Third spacing of fluid Dysrhythmias Tachycardia Gastric hypermotility

Tachycardia

When a client is in the compensatory stage of shock, which symptom occurs? Bradycardia Urine output of 45 cc/hour Tachycardia Respiratory acidosis

Tachycardia

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion? The client is in the compensatory stage of shock. The client is in the progressive stage of shock. The client will stabilize and be released by tomorrow. The client is in the irreversible stage of shock.

The client is in the compensatory stage of shock.

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? The drug should be discontinued immediately after blood pressure increases. The drug dose should be tapered down once vital signs improve. The client should have arterial blood gases drawn every 10 minutes during treatment. The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.

The drug dose should be tapered down once vital signs improve.

When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

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 ICU nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of: increased stroke volume. increased cardiac output. decreased heart rate. decreased venous return.

decreased venous return

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 blunt force trauma nausea

heart fails as effective pump blood volume decreases peripheral vascular dilation

Which of the following is NOT a category of shock? hepatic cardiogenic circulatory hypovolemic

hepatic

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? neurogenic shock septic shock anaphylactic shock hypovolemic shock

neurogenic shock

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 400 mL 500 mL 600 mL

300 mL

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? Blood products 5% albumin 6% dextran 6% hetastarch

5% albumin

A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated? Performing frequent oral care Maintaining the client in a supine position Suctioning the client every 15 minutes unless contraindicated Administering prophylactic antibiotics, as prescribed

Preforming frequent oral care

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. Assess the client who is at risk for shock. Administer vasoconstrictive medications to clients at risk for shock. Administer prophylactic packed red blood cells to clients at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Liver Kidneys Lungs Brain

Brain

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? Increase in diastolic pressure Decrease in respiratory rate Increase in systolic blood pressure Narrowed pulse pressure

Narrowed pulse pressure

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? Septic Anaphylactic Neurogenic Cardiogenic

Neurogenic

A nurse in the ICU receives report from the nurse in the ED about a new client 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 client is probably experiencing? Anaphylactic shock Neurogenic shock Septic shock Hypovolemic shock

Neurogenic shock

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? Initial Compensatory Progressive Irreversible

Progressive

Which is the most common type of shock? hypovolemic shock cardiogenic shock obstructive shock distributive shock

hypovolemic shock

The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock? Elevated systolic blood pressure Elevated mean arterial pressure Shallow, rapid respirations Bradycardia

Shallow, rapid respirations

The nurse is transferring a client who is in the progressive stage of shock into ICU from the medical unit. Nursing management of the client should focus on what intervention? Reviewing the cause of shock and prioritizing the client's psychosocial needs Assessing and understanding shock and the significant changes in assessment data to guide the plan of care Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock

Assessing and understanding shock and the significant changes in assessment data to guide the plan of care

A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury 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 the patient is probably experiencing? Anaphylactic shock Neurogenic shock Septic shock Hypovolemic shock

Neurogenic shock