N123 EAQ: Shock

When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect? Select all that apply. 1. Cyanosis 2. Cold skin 3. Weak pulse 4. Bradycardia 5. Hypertension

1. Cyanosis 2. Cold skin 3. Weak pulse Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted. Text Reference - p. 1633

When caring for a patient in acute septic shock, what should the nurse anticipate? 1. Infusing large amounts of intravenous (IV) fluids 2. Administering osmotic or loop diuretics 3. Administering IV diphenhydramine (Benadryl) 4. Assisting with insertion of a ventricular assist device (VAD)

1. Infusing large amounts of intravenous (IV) fluids Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock, but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock.

The health care provider prescribes a dose of dobutamine for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication? Select all that apply. 1. Monitor heart rate and blood pressure. 2. Stop infusion if tachydysrhythmias develop. 3. Always administer with sodium bicarbonate. 4. Administer through a central line. 5. Use a glass bottle for infusion.

1. Monitor heart rate and blood pressure. 2. Stop infusion if tachydysrhythmias develop. 4. Administer through a central line. Doubutamine is a sympathomimetic medication. When used in therapy with dobutamine, the patient's heart rate and blood pressure should be continuously monitored, as they may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended, because infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate, because it can get deactivated. Because dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. Text Reference - p. 1643

The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning? 1. PaO2 60 mm Hg 2. Blood pressure 100/56 mm Hg 3. Urine output 260 mL in eight hours 4. Heart rate 96 beats/minute

1. PaO2 60 mm Hg A PaO2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a blood pressure of 100/56 mm Hg and heart rate of 96 would not apply. A urine output of 260 cc/8 hrs is borderline but not reportable without a continued trending pattern. Text Reference - p. 1633

When examining a patient with septic shock, what symptoms would the nurse expect to find? Select all that apply. 1. Paralytic ileus 2. Gastrointestinal (GI) bleeding 3. Pulsus paradoxus 4. Distended jugular vein 5. Decreased urinary output

1. Paralytic ileus 2. Gastrointestinal (GI) bleeding 5. Decreased urinary output Patients suffering from septic shock may experience decreased tissue perfusion, which may result in a paralytic ileus, GI bleeding, and decreased urinary output. Pulsus paradoxus and jugular vein distension are found in obstructive shock and are mainly the result of compromised hemodynamics. Text Reference - p. 1637

The primary health care provider prescribes antibiotics and vasopressors for a patient. Which type of shock does the nurse expect to be treating? 1. Septic shock 2. Cardiogenic shock 3. Neurogenic shock 4. Anaphylactic shock

1. Septic shock Septic shock occurs in response to infection. Therefore, antibiotics are prescribed for a patient with septic shock. Cardiogenic shock occurs when systolic or diastolic function of the heart is impaired. Sympathomimetic drugs are used for the treatment of cardiogenic shock. Injury to the spinal cord at the fifth thoracic vertebra or above causes neurogenic shock. Vasconstricting medications are prescribed to prevent vasodilation for a patient in septic shock. Anaphylactic shock is a life-threatening allergic reaction to a sensitizing substance. Antihistamines, bronchodilators, and corticosteroids are used in the treatment of anaphylactic shock.

Which types of shock may cause reduced urinary output in a patient? Select all that apply. 1. Septic shock 2. Hypovolemic shock 3. Obstructive shock 4. Neurogenic shock 5. Anaphylactic shock 6. Cardiogenic shock.

1. Septic shock 2. Hypovolemic shock 3. Obstructive shock 6. Cardiogenic shock. Decreased urine output is a clinical manifestation of septic, hypovolemic, obstructive and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence.

The nurse reviews the medical record of a patient with pneumonia and notes that the patient has hypotension, hypothermia, leukocytosis, and hypoxemia. What should the nurse infer from these findings? 1. The patient has septic shock. 2. The patient has neurogenic shock. 3. The patient has cardiogenic shock. 4. The patient has hypovolemic shock.

1. The patient has septic shock. Septic shock is most commonly found in the patient having gram-negative bacterial infections, such as pneumonia. Because it is characterized by hypertension, hypothermia, leukocytosis, and hypoxemia in patients with infections, the nurse concludes that the patient has septic shock. Neurogenic shock is most commonly seen in the patient who has an injury. Cardiogenic shock is caused by cardiovascular disorders, such as a myocardial infarction and cardiomyopathy. Hypovolemic shock is caused by hemorrhage or trauma.

What is a manifestation of the irreversible stage of shock? 1. Delirium 2. Areflexia 3. Restlessness 4. Alterations in the level of consciousness

2. Areflexia Areflexia or loss of reflexes is a manifestation of the irreversible stage of shock. The progressive state of shock is associated with delirium. Restlessness and altered levels of consciousness indicate that the patient is in the compensatory stage of shock.

A patient admitted to the hospital after a motor vehicle accident (MVA) is in hypovolemic shock. On examination, the nurse finds that the patient is becoming anxious, and the urine output is decreasing. What appropriate action should the nurse perform? 1. Prepare for administering blood products. 2. Begin crystalloid fluid replacement. 3. Start fluids only if deterioration occurs. 4. Wait for the patient to compensate naturally.

2. Begin crystalloid fluid replacement. When the volume of blood loss is less than 30 percent, crystalloid fluid replacements are performed to reverse tissue dysfunction. Blood products are administered when the blood volume loss is more than 30 percent. The nurse should not wait for deterioration to occur to start the fluid replacement therapy. This is because the body can typically compensate naturally for a blood volume loss up to 15 percent. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies. Text Reference - p. 1633

Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest x-ray and increased levels of blood urea nitrogen (BUN)? 1. Septic 2. Cardiogenic 3. Obstructive 4. Hypovolemic

2. Cardiogenic Increased blood levels of glucose, nitrogen, cardiac markers and presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1635

A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this? 1. Neurogenic shock 2. Cardiogenic shock 3. Hypovolemic shock 4. Anaphylactic shock

2. Cardiogenic shock A patient with cardiogenic shock shows peripheral hypoperfusion presenting as cyanosis and has crackles on auscultation of the lungs due to pulmonary congestion. In neurogenic shock, the patient demonstrates symptoms related to the injury such as hypotension and bradycardia. The patient in hypovolemic shock may experience tachycardia as a late sign. In anaphylactic shock, the patient may experience wheezing and stridor. Text Reference - p. 1633

When examining a patient in the progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply. 1. Increased motility and peristalsis 2. Increased likelihood of GI ulcers 3. Increased ability to absorb nutrients 4. Increased risk of GI bleeding 5. Increased risk of bacterial migration from the GI tract to the bloodstream.

2. Increased likelihood of GI ulcers 4. Increased risk of GI bleeding 5. Increased risk of bacterial migration from the GI tract to the bloodstream. In the progressive stage of shock, the GI system gets affected by prolonged decreased tissue perfusion. As the blood supply to the GI tract is decreased, the normally protective mucosal barrier becomes ischemic. This ischemia predisposes the patient to ulcers and GI bleeding. It also increases the risk of bacterial migration from the GI tract to the blood. The decreased perfusion to the GI tract also results in a decreased ability to absorb nutrients, decreased motility, and slowed peristalsis. Text Reference - p. 1639

A patient in shock is receiving 0.9 % NaCl (normal saline solution-NSS). Which nursing intervention is appropriate for this patient? 1. Monitor the patient's vital signs 2. Monitor for the signs of circulatory overload 3. Monitor for signs of hypernatremia in the patient 4. Monitor for allergic reactions and acute renal failure

2. Monitor for the signs of circulatory overload Circulatory overload occurs due to fluid overload. Continuous infusion of 0.9% NaCl increases the fluid volume in the body and may cause circulatory overload. The patient's vital signs must be checked during transfusion of blood or blood products because they could cause an infection or an allergic reaction. Hypernatremia occurs when the patient is on 1.8%, 3%, and 5% NaCl infusions. Infusion of dextran-40 has a tendency to precipitate allergic reactions and acute renal failure. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. Text Reference - p. 1642

Which type of shock is associated with bradycardia? 1. Septic shock 2. Neurogenic shock 3. Hypovolemic shock 4. Anaphylactic shock

2. Neurogenic shock Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Reduction in preload, capillary refill and stroke volume are clinical manifestations of hypovolemic shock. Chest pain is seen in anaphylactic shock. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 1635

A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply. 1. Pallor 2. Pruritus 3. Flushing 4. Urticaria 5. Cold, clammy skin

2. Pruritus 3. Flushing 4. Urticaria Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion. Text Reference - p. 1636

The nurse is caring for a patient who has hypovolemic shock. Which medical diagnosis does the nurse suspect? 1. Insect bite 2. Severe burns 3. Pulmonary embolism 4. Myocardial infarction

2. Severe burns Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. Insect bites may lead to an anaphylactic shock state. Pulmonary embolism may lead to an obstructive shock state, and myocardial infarction may lead to a cardiogenic shock state. Text Reference - p. 1632

When managing a patient with shock, which appropriate actions should the nurse take as part of nutritional therapy? Select all that apply. 1. Plan enteral feeding to meet at least 50 percent of calorie requirements. 2. Start enteral nutrition within the first 24 hours. 3. Wait until the patient recovers to start with enteral nutrition. 4. Start a slow continuous drip of small amounts of enteral feedings. 5. Start parenteral nutrition if enteral feedings are contraindicated.

2. Start enteral nutrition within the first 24 hours. 4. Start a slow continuous drip of small amounts of enteral feedings. 5. Start parenteral nutrition if enteral feedings are contraindicated. Enteral nutrition should ideally begin within the first 24 hours. It is important because it enhances the perfusion of the (gastrointestinal) GI tract and helps to maintain the integrity of the gastrointestinal mucosa. Enteral feeding should be started with a slow continuous drip of small amounts of enteral feedings. If enteral feedings are contraindicated, parenteral feedings can be started. Enteral feeding should be planned to meet at least 80 percent of the total calorie requirements, but if it is not feasible, parenteral feeding should be started. Nutritional therapy should start as early as possible. The nurse should not wait for the patient to recover before starting nutritional therapy. Text Reference - p. 1644

A patient's localized infection has progressed to the point where septic shock now is suspected. What medication is an appropriate treatment modality for this patient? 1. Insulin infusion 2. Intravenous (IV) administration of epinephrine 3. Aggressive IV crystalloid fluid resuscitation 4. Administration of nitrates and β-adrenergic blockers

3. Aggressive IV crystalloid fluid resuscitation Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock. Text Reference - p. 1636

A patient is brought to the emergency department (ED) after multiple bee stings. On assessment, the nurse finds that the patient has edema on the lips and tongue as well as chest pain, dizziness, wheezing, and stridor. What type of shock should the nurse document this as? 1. Septic shock 2. Neurogenic shock 3. Anaphylactic shock 4. Obstructive shock

3. Anaphylactic shock Anaphylactic shock is an acute, life-threatening hypersensitivity reaction to a sensitizing substance that, in this case, is insect venom. The reaction quickly causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space. The consequences of these pathophysiologic processes include edema on the lips and tongue, chest pain, wheezing, and stridor. Sepsis is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic (T5) vertebra or above. Obstructive shock develops when a physical obstruction to blood flow occurs with decreased cardiac output. Text Reference - p. 1636

Which form of shock is associated with pruritus? 1. Septic shock 2. Neurogenic shock 3. Anaphylactic shock 4. Obstructive shock

3. Anaphylactic shock Pruritus is a clinical manifestation of anaphylactic shock. Septic shock is initially associated with warm and flushed skin with later changes that include cool and mottled skin. Warm or cool and dry skin is a sign of neurogenic shock. Pale, cool and clammy skin is a sign of obstructive shock. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses. Text Reference - p. 1635

The nurse is administering oxygen therapy to a patient in septic shock. What are the possible factors that directly affect oxygen delivery in the patient and should be monitored? Select all that apply. 1. Urine output 2. White blood cells 3. Cardiac output 4. Available hemoglobin 5. Arterial oxygen saturation

3. Cardiac output 4. Available hemoglobin 5. Arterial oxygen saturation Oxygen delivery depends on cardiac output, available hemoglobin, and arterial oxygen saturation (SaO2). The amount of blood that the heart pumps to the body may decide the amount of oxygen delivered to the tissues. Hemoglobin, the protein content in red blood cells, is responsible for carrying oxygen molecules. Low hemoglobin means a low oxygen supply to the tissues. Arterial oxygen saturation indicates the total oxygen carried by the blood in the arteries and implies the level of tissue oxygenation. The urine output and white blood cells are also important parameters to be monitored in a patient who suffers from a shock. However, these do not impact the oxygen delivery directly. Text Reference - p. 1641

A patient is admitted to the hospital with a suspected diagnosis of obstructive shock. What could be the possible causes of this type of shock? Select all that apply. 1. Hypersensitivity to antibiotics 2. Spinal cord injury 3. Cardiac tamponade 4. Tension pneumothorax 5. Superior vena cava syndrome

3. Cardiac tamponade 4. Tension pneumothorax 5. Superior vena cava syndrome Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Hypersensitivity to antibiotics may cause anaphylactic shock. Spinal cord injury may lead to neurogenic shock. Text Reference - p. 1637

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of: 1. A secondary MI 2. Pulmonary edema 3. Cardiogenic shock 4. Fatal dysrhythmias

3. Cardiogenic shock One of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension.

he nurse is caring for a patient who developed cardiogenic shock. Which medical diagnosis does the nurse suspect? 1. Urosepsis 2. Hemorrhage 3. Myocardial infarction 4. Tension pneumothorax

3. Myocardial infarction Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state. Text Reference - p. 1633

The nurse recalls that cardiogenic shock is differentiated from other forms of shock because the patient with cardiogenic shock typically experiences: 1. Hypotension 2. Dysrhythmias 3. Volume excess 4. Volume depletion

3. Volume excess In cardiogenic shock the heart fails as a pump. This usually results in fluid retention and poor perfusion of organs, including the kidneys, which adds to the fluid volume excess. As cardiogenic shock progresses, hypotension will develop, but it is not the cause of cardiogenic shock. Dysrhythmias may or may not be present with cardiogenic shock. Volume depletion is not generally seen with cardiogenic shock. It is, however, seen more with hypovolemic or distributive forms of shock. Text Reference - p. 1633

What laboratory finding correlates with a medical diagnosis of cardiogenic shock? 1. Decreased liver enzymes 2. Increased white blood cells 3. Decreased red blood cells, hemoglobin, and hematocrit 4. Increased blood urea nitrogen (BUN) and serum creatinine levels

4. Increased blood urea nitrogen (BUN) and serum creatinine levels The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, whereas white blood cell levels typically do not increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? 1. Acute pain 2. Impaired tissue integrity 3. Decreased cardiac output 4. Ineffective tissue perfusion

4. Ineffective tissue perfusion The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output, because circulation is a priority. Acute pain may occur, but is not a priority at this time. Tissue integrity is not impaired. Text Reference - p. 1633

Which drug causes arterial and venous dilation? 1. Dopamine 2. Vasopressin 3. Phenylephrine 4. Sodium nitroprusside

4. Sodium nitroprusside Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Text Reference - p. 1643

If the patient in shock is to receive 1000 mL of normal saline in two hours, at what rate should the infusion pump be set? Fill in the blank. ___mL/hour

500 mL/Hr (1000 mL divided by two hours)