Chapter 34: Shock

4. Which client will the nurse recognize as having a higher risk for obstructive shock? A. 32-year-old with a pulmonary embolus B. 42-year-old with stable angina C. 52-year-old with chronic atrial fibrillation D. 72-year-old with a history of heart failure

4. A Obstructive shock is caused by problems that impair the ability of the normal heart to pump effectively. The heart itself remains normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. Although the most common cause of obstructive shock is cardiac tamponade, other causes include arterial stenosis, pulmonary embolism, pulmonary hypertension, pericarditis, thoracic tumor, and tension pneumothorax. The other health problems listed are causes associated with cardiogenic shock.

20. Which specific client symptom indicates to the nurse that septic shock (Sepsis-3) may be present? A. Hypotension B. Pale, clammy skin C. Anxiety and confusion D. Oozing of blood at the IV site

20. D With septic shock, compared to other types of shock, inappropriate clotting occurs with the formation of microthrombi that use available clotting factors and platelets. When these substances are depleted by excessive microclotting, bleeding can occur from any orifice or site of tissue injury. The other symptoms, although present in septic shock, are also present in every other type of shock and are not specific for septic shock.

1. Which statements about shock are true? Select all that apply. A. Affects all body organs B. Occurs only in the acute care setting C. Is a whole-body response to tissue hypoxia D. Results in widespread abnormal cellular metabolism E. Is classified as a disease rather than a discreet disorder F. May occur in older clients in response to urinary tract infections

1. A, C, D, F Shock is widespread abnormal cellular metabolism that occurs when gas exchange with oxygenation and tissue perfusion needs are insufficient to maintain cell function. It is a condition rather than a disease and is the "whole-body" response that occurs with tissue hypoxia. All body organs are affected by shock and either work harder to adapt and compensate for reduced gas exchange or perfusion or fail to function because of hypoxia. Urinary tract infections that enter the bloodstream (urosepsis) is a common cause of shock in older clients. Shock can occur in any setting.

10. Which laboratory values in a client with hypovolemic shock will the nurse associate with the progressive stage of shock? Select all that apply. A. Arterial blood pH 7.32 B. Serum lactate 9 mg/dL (1.03 mmol/L) C. Sodium 147 mEq/L (mmol/L) D. Blood urea nitrogen 15 mg/dL E. Potassium 6.3 mEq/L (mmol/L) F. Neutrophil count 5,000/mm3 (5 x 109/L)

10. A, B, E Laboratory indicators of the progressive stage of hypovolemic shock are a low blood pH, along with rising lactic acid and potassium levels. The sodium level rises during the compensatory stage. The level listed is only slightly higher than normal. The BUN is within the normal range. The neutrophil count is within the normal range.

11. Which actions are most appropriate for the nurse to take first when a client with blunt trauma to the abdomen who has been NPO for several hours now reports thirst and anxiety? Select all that apply. A. Obtain an order for a stat hematocrit and hemoglobin. B. Get the client a few ice chips or a moistened swab. C. Compare current vital signs to baseline. D. Check for obvious blood in the urine. E. Measure abdominal girth. F. Increase the IV rate.

11. C, E A client with blunt trauma to the abdomen may have internal bleeding and is at risk for shock. Thirst and anxiety are subjective symptoms of shock. The nurse would assess for other indications of shock or internal bleeding by first assessing vital signs and comparing them to the client's baseline and measure abdominal girth. If the vital signs or abdominal assessment are consistent with shock, the nurse will notify the Rapid Response Team who would order a stat hematocrit and hemoglobin. Although keeping an IV open and available is important, until the source of bleeding is found and corrected, the IV rate may not be increased in order to slow any hemorrhage. The kidneys are located on the back wall and not usually directly involved in abdominal trauma. Until assessment is complete, the client is kept NPO.

12. Which assessment has the highest priority for the nurse to perform to prevent harm when caring for a client in hypovolemic shock who is receiving IV sodium nitroprusside? A. Asking about chest pain B. Determining mental status C. Checking blood pressure every 15 minutes D. Checking extremities for color and perfusion

12. C Sodium nitroprusside improves myocardial perfusion by dilating coronary arteries rapidly for a short time. This action also occurs in systemic blood vessels and can result in dangerously low blood pressure. Thus, the nurse assesses blood pressure every 15 minutes while a client is receiving this drug. The drug does not cause chest pain and does not cause peripheral vasoconstriction that could interfere with perfusion of extremities. The drug's effect on mental status is related to blood pressure decreases.

13. Which statement made by a client at high risk for hypovolemic shock is of greatest concern to the nurse? A. "I live alone in my house and my family lives in a different state." B. "Do you have any idea when I might go home? No one is feeding my cat." C. "Something feels wrong, but I'm not sure what is causing me to feel this way." D. "I would usually go golfing with my friends today. I hope they're not worried about me."

13. C Anxiety and a sense of impending doom are common changes in mental status that occur with the hypoxemia and sympathetic nervous system associated with shock.

14. Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective? A. Urine output increases from 5 mL/hr to 25 mL/hr. B. Pulse pressure decreases from 35 mm Hg to 28 mm Hg. C. Respiratory rate increases from 22 breaths/min to 26 breaths/min. D. Core body temperature increases from 98.2°F (36.8°C) to 98.8°F (37.1°C).

14. A During shock, the kidneys and baroreceptors sense an ongoing decrease in MAP 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 from normal. 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 was not effective, urine output would not increase.

15. For which change in condition will the nurse teach a client, who is discharged and at continued risk for fluid loss, to check for daily at home? A. Elevated temperature and itchiness B. Loss of taste sensation and appetite C. Numbness of the fingers and toes D. Reduced urine output and light-headedness

15. D Reduced urine output and light-headedness are early indicators of hypovolemia related to fluid loss. The other options are not associated with any problem related to hypovolemia resulting from fluid loss.

16. For which client problems associated with hypovolemic shock will the nurse specifically prepare to administer a blood product rather than an IV crystalloid? Select all that apply. A. Acidosis B. Hypoxemia C. Dehydration D. Hypotension E. Hyponatremia F. Low hematocrit and hemoglobin levels

16. B, F Blood products, such as packed red blood cells (PRBCs), are used when shock is caused by blood loss resulting in hypoxemia. PRBCs increase hematocrit and hemoglobin levels along with some fluid volume. Crystalloid fluids contain only minerals, salts, sugars, and nonprotein substances. They can help restore volume, electrolyte balance, and may buffer lactic acid. However, these fluids neither correct low hematocrit or hemoglobin levels nor correct hypoxemia.

17. Which actions are priorities for the nurse to perform to prevent harm for a client with hypovolemic shock who is receiving an infusion of dobutamine? Select all that apply. A. Assessing hourly urine output B. Assessing for chest pain throughout the infusion C. Covering the infusion bag to protect it from light D. Measuring blood pressure at least every 15 minutes E. Ensuring the drug is infused only with Ringer's lactate F. Checking the infusion site every 30 minutes for extravasation

17. B, D, F Dobutamine is a beta-adrenergic agonist and a positive inotropic agent that can improve cardiac contractility. The increased contractility increases cardiac muscle oxygen consumption, which may not be met during shock, and can lead to angina or myocardial infarction. Although the main action is in the heart muscle, it also acts on blood vessels and can cause a transient hypotension from vascular dilation. When doses are too high, vasoconstriction can occur and is an indication of overdose. In addition, if extravasation occurs local vasoconstriction can cause tissue damage. The drug is not light sensitive and can be run with other crystalloids, not just Ringer's lactate. Assessing urine output is not the priority when administering dobutamine.

18. Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? A. 75-year-old with hypertension and early Alzheimer disease B. 68-year-old who is 2 days postoperative from bowel surgery C. 54-year-old with moderate asthma and severe degenerative joint disease of the right knee D. 80-year-old community dweller with no other health problems undergoing cataract surgery

18. B This client has several risk factors. First, he or she is an older adult. Immune function decreases with age. The greatest risk factor is the recent bowel surgery. Not only does major surgery further reduce the immune response but also the bowel cannot be "sterilized" for surgery. Thus, bacteria in the bowel have the chance to escape the site and enter the bloodstream when the bowel is disrupted.

19. Which client parameters will the nurse report to the health care provider as consistent with the quick Sequential Organ Failure Assessment (qSOFA) indicating the possible presence of sepsis or septic shock? Select all that apply. A. Core body temperature 100°F (37.8°C) B. Eyes are open but does not respond to questions C. Respiratory rate of 28 breaths/min D. SpO2 is 94% primary E. Systolic blood pressure of 92 mm Hg F. Urine output of 18 mL/hr

19. B, C, E The quick Sequential Organ Failure Assessment (qSOFA) can quickly alert clinicians to the need for further assessment for organ dysfunction. This assessment has three parameters and clients are assigned one point for each abnormal parameter. Abnormal parameters include: Systolic blood pressure ≤ 100 mm Hg Respiratory rate ≥ 22 breaths/min Any change in mental status

2. Why are the clinical signs and symptoms of most types of shock the same regardless of what specific events or conditions caused the shock to occur? A. The blood, blood vessels, and heart are directly connected to each other so that when one is affected, all three are affected. B. Because blood loss occurs with all types of shock, the most common first manifestation is hypotension. C. Every type of shock interferes with oxygenation and metabolism of all cells in the same sequence. D. The sympathetic nervous system is triggered by any type of shock and initiates the stress response.

2. D Most clinical signs and symptoms of shock are similar regardless of what starts the process or which tissues are affected first. These common changes result from physiologic adjustments (compensatory mechanisms) in the 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.

21. Which specific drug therapy will the nurse anticipate for management of the client who has septic shock? A. Antibiotics B. Inotropics C. Crystalloids D. Antidysrhythmics

21. A Septic shock starts with a localized infection that becomes systemic. Specific therapy for sepsis and septic shock (Sepsis-3) is the use of antibiotics. Inotropics and crystalloids are used for many types of shock, including septic shock. Antidysrhythmics are used whenever life-threatening dysrhythmias are present.

22. Which complication will the nurse remain alert for in a client who has septic shock? A. Psychosis B. Skin necrosis C. Febrile seizures D. Acute respiratory distress syndrome (ARDS)

22. D The lungs are susceptible to damage during septic shock, and the complication of ARDS may occur. ARDS in septic shock is caused by the continued systemic inflammatory response syndrome (SIRS) increasing the formation of oxygen free radicals, which damage lung cells.

23. Which symptom in a client with sepsis does the nurse consider a late indication of septic shock? A. Warm skin B. Bounding pulse C. Severe hypotension D. Decreased urine output

23. C Late in septic shock, the client has hypovolemia and greatly decreased cardiac output with severe hypotension. Decreased urine output is an earlier indicator of shock. Although earlier in sepsis the skin is warm from vasodilation, in late septic shock the skin is cool, clammy, and cyanotic. The pulse is weak and thready.

24. How will the nurse interpret a change in the white blood cell (WBC) count of a client with sepsis in which the band neutrophil count is increasing and the segmented neutrophil count is decreasing? A. Antibiotic therapy is successful. B. The infection is becoming worse. C. The client is allergic to the drug therapy. D. Disseminated intravascular coagulation (DIC) is now present.

24. B When the band neutrophil count is increasing and the segmented neutrophil count is decreasing, a left shift is occurring, in which the bone marrow is becoming depleted of mature neutrophils that can fight the infection. The infection is getting worse, indicating that antibiotic therapy is not effective and the client's ability to fight infection is greatly decreased. Changes in these specific WBCs are not associated with an allergic reaction or DIC.

25. When sepsis is diagnosed in a client, when will the nurse initiate the prescribed antibiotic therapy? A. Within the first hour after diagnosis B. Within the first 24 hours after diagnosis C. After the results of blood cultures are known D. When blood lactate levels have increased to 9 mg/dL (1.03 mmol/L)

25. A Antibiotic therapy is initiated as soon as possible, preferably within the first hour after diagnosis, even if blood cultures have not been obtained. It is not delayed until after blood culture results are known. Lactate levels are used to diagnose the condition, not guide the timing of antibiotic therapy.

26. Which blood product type does the nurse anticipate will be ordered to infuse first in a client who has septic shock with poor clotting and hemorrhage? A. Packed red blood cells (PRBCs) B. Fresh frozen plasma (FFP) C. Clotting factors D. Platelets

26. D In a client with septic shock who has poor clotting and bleeding, it is most likely that disseminated intravascular coagulation (DIC) has occurred and consumed all of the client's available platelets, which are an absolute necessity for appropriate clotting to occur. These are given first.

27. What is the nurse's best first action when a client who has sepsis is found to have a blood glucose level of 310 mg/dL? A. Check the electronic health record to determine when the last dose of antidiabetic drug was given. B. Ask the family how long the client has had diabetes. C. Notify the primary health care provider. D. Document the finding as the only action.

27. C Sepsis alone can elevate blood glucose levels in any client. Levels above 180 mg/dL are associated with poor outcomes and management must be started immediately. The nurse's best first action is to notify the primary health care provider immediately.

28. Which changes in condition will the nurse teach a client who is being discharged after successful management of sepsis to check daily as an indicator of a new or ongoing infection? Select all that apply. A. Shortness of breath B. Temperature elevation C. Cloudy, foul-smelling urine D. New onset of a productive cough E. Paleness or blue tinge to mouth membranes F. Redness and tenderness of an open skin lesion

28. A, B, C, D, E, F All conditions listed above can be indicators of a new or ongoing infection.

3. Which client does the nurse consider to be at highest risk for neural-induced distributive shock? A. 25-year-old receiving 500 mg of penicillin IV B. 47-year-old with sudden-onset severe chest pain and dyspnea C. 21-year-old who has received 4 mg of morphine IV for acute pain D. 82-year-old who has had severe vomiting and diarrhea for 2 days

3. C Both acute pain and morphine can lead to neural-induced distributive shock. At first, acute pain stimulates the sympathetic nervous system. However, the parasympathetic system over-rides the sympathetic division. This interference together with morphine acting within the central nervous system result in decreased sympathetic tone to blood vessel smooth muscles, causing widespread vasodilation and reduced mean arterial pressure. Option A is incorrect. The type of shock possibly produced by a reaction to penicillin is anaphylactic shock, a type of chemical-induced distributive shock. Option B is incorrect. The type of shock associated with sudden-onset severe chest pain and dyspnea is cardiogenic shock from an acute myocardial infarction. Option D is incorrect. The type of shock associated with prolonged vomiting and diarrhea is hypovolemic shock with true volume depletion as a result of dehydration.

5. Which conditions will the nurse consider as increasing any client's risk for hypovolemic shock? Select all that apply. A. Hypoglycemia B. Diuretic therapy C. Severe head injury D. Prolonged diarrhea E. Liver failure with ascites F. Continuous nasogastric suction G. Large draining abdominal wound

5. B, D, F, G In addition to loss of blood, hypovolemic shock can be caused by dehydration that decreases circulating blood volume. Conditions increasing the risk for dehydration-induced hypovolemic shock include fluid losses resulting from diuretic therapy, diarrhea, continuous nasogastric suction, and excessive wound drainage. Hypoglycemia does not result in fluid loss. Severe head injury can lead to neural-induced distributive shock, not hypovolemic shock. Liver failure with ascites is another cause of distributive shock caused by capillary leak.

6. Which changes in vital signs of a client in the early postoperative period indicates to the nurse that the client may be in the initial stage of hypovolemic shock? Select all that apply? A. Increased heart rate B. Increased respiratory rate C. Decreased systolic blood pressure D. Decreased urine output E. Increased diastolic blood pressure F. Increased pulse pressure

6. A, B, E The initial stage of shock is characterized by sympathetic nervous system compensation with vasoconstriction. Thus, the indicators of the initial stage of hypovolemic shock are subtle and include only increased heart and respiratory rates or a slight increase in diastolic blood pressure.

7. Which subjective symptom will the nurse expect to find in a client during the compensatory stage of hypovolemic shock? A. Thirst B. Hunger C. Headache D. Numbness of the fingers and toes

7. A Hormonal compensation for hypovolemic shock includes secretion of antidiuretic hormone (ADH), renin, and aldosterone as a result of decreased tissue perfusion. Subjective changes of this compensation include thirst and anxiety.

8. Which body area on a client with darker skin who is at high risk for shock will the nurse examine for indications of pallor and cyanosis? A. Oral mucous membranes B. Soles of the hands and feet C. Earlobes and bridge of the nose D. Sclera closest to the inner corner of the eye

8. A In dark-skinned clients, pallor or cyanosis is best assessed in the oral mucous membranes. The hands and feet may indicate a temperature change but are not reliable indicators of pallor or cyanosis. Sclera can only indicate the possible presence of jaundice. Although the earlobes and nose can become cyanotic, this would occur much later than changes observed in the oral mucous membranes.

9. Which change in laboratory values or clinical symptoms in a client with hypovolemic shock indicates to the nurse that current therapy may need to be changed? A. Urine output increases from 5 mL/hr to 6 mL/hr. B. Pulse pressure decreases from 28 mm Hg to 22 mm Hg. C. Serum potassium level increases from 3.6 mEq/L to 3.9 mEq/L. D. Core body temperature increases from 98.2°F (36.8°C) to 98.8°F (37.1°C).

9. B A compensatory response to shock is vasoconstriction. Initially, the diastolic pressure increases but systolic pressure remains the same. As a result, the difference between the systolic and diastolic pressures (pulse pressure), is smaller or "narrower." When interventions are inadequate and shock worsens, systolic pressure decreases as cardiac output decreases. This causes the pulse pressure to narrow even further, indicating that shock is progressing. Although an increase in urine output usually signals improvement, a change of 1 1 mL/hr is within the margin of measurement error and is meaningless in this situation.