Patho Chapter 23- Shock

What term should the nurse document for a detached blood clot? A. Thrombus B. Infarction C. Embolus D. Thromboembolus

Thromboembolus

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A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. check the blood pressure. b. obtain an oxygen saturation. c. attach a cardiac monitor. d. check level of consciousness.

1.Correct Answer: B Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.

A patient has been researching cardiac cells on the internet. Which information indicates the patient has a good understanding? Cardiac cells can withstand ischemic conditions for _____ minutes before irreversible cell injury occurs. A. 5 B. 60 C. 20 D. 90

20

The nurse is assisting in the care of several patients in the critical care unit. Which patient is at greatest risk for developing multiple organ dysfunction syndrome (MODS)? a-22-year-old patient with systemic lupus erythematosus who is admitted with a pelvic fracture after a motor vehicle accident b-48-year-old patient with lung cancer who is admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c-65-year-old patient with coronary artery disease, dyslipidemia, and primary hypertension who is admitted for unstable angina d-82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection

82-year-old patient with type 2 diabetes mellitus and chronic kidney disease who is admitted for peritonitis related to a peritoneal dialysis catheter infection Rationale: A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Individuals at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

A 60-year-old male presents to his primary care provider reporting chest pain. He is diagnosed with atherosclerosis. This disease is caused by: A. Abnormal thickening and hardening of vessel walls B. Abnormally dilated arteries and veins C. Autonomic nervous system imbalances D. Arterial wall thinning and weakening

Abnormal thickening and hardening of vessel walls

A 28-year-old female presents to the ER reporting severe chest pain that worsens with respirations or lying down. She has a fever, tachycardia, and a friction rub. Based upon the assessment findings, the nurse determines the patient is experiencing: A. Myocardial infarction (MI) B. Stable angina C. Acute pericarditis D. Pericardial effusion

Acute pericarditis

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

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

A 10-year-old male presents with fever, lymphadenopathy, arthralgia, and nose bleeds. He is diagnosed with rheumatic heart disease. While planning care, which characteristic changes should the nurse remember? A. High fevers that damage collagen in valve leaflets B. Blood-borne organisms that adhere to the valvular surface C. Antigens that bind to the valvular lining, triggering an autoimmune response D. Rheumatoid factor in the blood, stimulating valvular degeneration

Antigens that bind to the valvular lining, triggering an autoimmune response

Upon assessment of the patient, the nurse finds a widened pulse pressure and throbbing peripheral pulses. Which valve disorder does the nurse suspect? A. Mitral regurgitation B. Aortic stenosis C. Mitral stenosis D. Aortic regurgitation

Aortic regurgitation

A 67-year-old female was previously diagnosed with rheumatic heart disease. Tests reveal lipoprotein deposition with chronic inflammation that impairs blood flow from the left ventricle into the aorta. Which of the following is the most likely diagnosis recorded on the chart? A. Mitral regurgitation B. Aortic stenosis C. Mitral stenosis D. Aortic regurgitation

Aortic stenosis

When a patient asks the nurse what is the most common cause of myocardial ischemia, which statement is the correct response? The most common cause of myocardial ischemia is: A. Idiopathic vasospasm B. Atherosclerosis C. Venous emboli D. Arterial emboli from heart valve

Atherosclerosis

A 50-year-old male visits the cardiologist for an EKG. Results indicate that he has no PR interval and a variable QRS rate with rhythm irregularity. Which of the following is the most likely diagnosis to be recorded on the chart? A. Atrial tachycardia B. Idioventricular rhythm C. Sinus dysrhythmia D. Atrial fibrillation

Atrial fibrillation

A 30-year-old female presents to her primary care provider with fever, cardiac murmur, and petechial skin lesions. She is diagnosed with infective endocarditis. When the patient wants to know what caused the disease, what is the nurse's best response? The most likely cause of the disease is: A. Viruses B. Bacteria C. Parasites D. Fungi

Bacteria

For an infection to progress to septic shock, which of the following factors should the nurse determine occurred? A. The infection must be gram negative. B. Bacteria must enter the bloodstream. C. The individual must be immunosuppressed. D. The myocardium must be impaired.

Bacteria must enter the bloodstream

A 65-year-old male presents for a routine checkup. A blood pressure check reveals a systolic pressure of 160 mm Hg and a diastolic pressure of 70 mm Hg. Which of the following is the most likely cause of this type of pressure elevation? A. Lung disease B. Rigidity of the aorta C. Vasospasm D. Decreased sodium intake

Rigidity of the aorta

Individuals with Raynaud disease need to be counseled to avoid which of the following conditions to prevent severe symptoms? A. Allergic reactions B. Cold exposure C. Hot water immersion D. Tissue injury

Cold exposure

A 60-year-old male is diagnosed with cerebral aneurysm. Where does the nurse suspect the cerebral aneurysm is located? A. Basilar artery B. Vertebral arteries C. Carotid arteries D. Circle of Willis

Circle of Willis

5. When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a. cardiac output is increased and the central venous pressure (CVP) is low. b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c. heart rate is decreased, and the systemic vascular resistance is low. d. cardiac output is decreased and the PAWP is high.

Correct Answer: A Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.

A nurse recalls acute orthostatic hypotension can be caused by (select all that apply): A. Drug action B. Starvation C. Exercise D. Volume depletion E. Prolonged immobility

Drug action Starvation Volume depletion Prolonged immobility

A patient wants to know what causes atherosclerosis. How should the nurse respond? In general, atherosclerosis is caused by: A. Endothelial injury and inflammation B. Congenital heart disease C. High serum cholesterol levels D. An increase in antithrombotic substances

Endothelial injury and inflammation

A 42-year-old female is diagnosed with constrictive pericarditis. The nurse assesses the blood pressure for decreased cardiac output because of: A. Pericardial effusions B. Fibrosis and calcification of the pericardial layers C. Hemorrhage in the pericardial cavity D. Cardiomyopathy

Fibrous and calcification of the pericardial layers

A 30-year-old Caucasian female was recently diagnosed with primary hypertension. She reports that she eats fairly well, usually having red meat and potatoes daily. She also reports that her father has hypertension as well. A nurse determines which of the following risk factors is most likely associated with this diagnosis? A. Race B. Age C. Diet D. Genes

Genes

The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy b- Hyperglycemia in the absence of diabetes c-Respiratory rate of seven breaths per minute d-Bradycardia with sudden increase in blood pressure

Hyperglycemia in the absence of diabetes Rationale: Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.

A nurse is planning care for a patient in shock. Which principle should the nurse remember? During shock states, glucose uptake is usually: A. Normal B. Enhanced C. Energy intensive D. Impaired

Impaired

A 68-year-old male presents to the ER reporting chest pain. He has a history of stable angina that now appears to be unstable. He most likely has: A. Decreased myocardial oxygen demand B. Impending myocardial infarction (MI) C. Electrical conduction problems in the heart D. Mild to moderate atherosclerosis

Impending myocardial infarction (MI)

A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis? a-Acute pain b-Impaired tissue integrity c-Decreased cardiac output d-Ineffective tissue perfusion

Ineffective tissue perfusion Rationale: The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.

When caring for a patient in acute septic shock, what should the nurse anticipate? A. Infusing large amounts of IV fluids B. Administering osmotic and/or loop diuretics C. Administering IV diphenhydramine (Benadryl) D. Assisting with insertion of a ventricular assist device (VAD)

Infusing large amounts of IV fluids

A 52-year-old female is diagnosed with coronary artery disease. The nurse assesses for myocardial: A. Necrosis B. Inflammation C. Ischemia D. Hypertrophy

Ischemia

A 60-year-old female was diagnosed with mitral stenosis. As a result, the nurse realizes the patient has incomplete emptying of the: A. Left ventricle B. Left atrium C. Right atrium D. Right ventricle

Left atrium

A 73-year-old female has increased pulmonary pressure resulting in right heart failure. The nurse should monitor for a possible complication because a potential cause for her heart to fail is: A. Pericarditis B. Hypertension C. Acute pneumonia D. Left heart failure

Left heart failure

A nurse is teaching staff about endocarditis. Which information should the nurse include? Inflammatory cells have difficulty limiting the colonization of microorganisms in infective endocarditis because the: A. Colonies overwhelm the phagocytes. B. Microorganisms are resistant. C. Valves are avascular. D. Microorganisms are sequestered in a fibrin clot.

Microorganisms are sequestered in a fibrin clot

A nurse recalls the most common cardiac valve disease in the United States, which tends to be most prevalent in young women, is: A. Tricuspid valve prolapse B. Pulmonary stenosis C. Mitral valve prolapse D. Aortic stenosis

Mitral valve prolapse

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A) Avoid elevating head of bed. B) Check temperature every 2 hours. C) Monitor breath sounds frequently. D) Assess skin for flushing and itching.

Monitor breath sounds frequently.

While planning care for a patient with superior vena cava syndrome (SVCS), which principle should the nurse remember? SVCS is a progressive _____ of the superior vena cava (SVC) that leads to venous distention of the upper extremities and head. A. Distention B. Occlusion C. Sclerosis D. Inflammation

Occlusion

A 55-year-old male died of a myocardial infarction. Autopsy would most likely reveal: A. Embolization of plaque from the aorta B. Platelet aggregation within the atherosclerotic coronary artery C. Decreased ventricular diastolic filling time D. Smooth muscle dysplasia in the coronary artery

Platelet aggregation within the atherosclerotic coronary artery

Most cases of combined systolic and diastolic hypertension have no known cause and are documented on the chart as _____ hypertension. A. Secondary B. Congenital C. Acquired D. Primary

Primary

A 51-year-old male is at the health clinic for an annual physical exam. After walking from the car to the clinic, he developed substernal pain. He also reported discomfort in his left shoulder and his jaw, lasting 2 to 3 minutes and then subsiding with rest. He indicates that this has occurred frequently over the past few months with similar exertion. The nurse suspects he is most likely experiencing: A. Prinzmetal angina B. Myocardial infarction (MI) C. Unstable angina D. Stable angina

Prinzmetal angina

A 65-year-old male is diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance. Which of the following heart failures should the nurse assess for in this patient? A. Low-output failure B. Left heart failure C. Right heart failure D. High-output failure

Right heart failure

When a patient with left heart failure starts to have a cough and dyspnea, which principle should the nurse remember? Pulmonary symptoms, common to left heart failure, are a result of: A. Bronchoconstriction B. Decreased cardiac output C. Pulmonary vascular congestion D. Inflammatory pulmonary edema

Pulmonary vascular congestion

A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of: a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

Septic Shock Rationale: Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. To meet the diagnostic criteria for sepsis, the patient's temperature must be higher than 100.9° F (38.3° C), or the core temperature must be lower than 97.0° F (36° C). Hemodynamic parameters for septic shock include elevated heart rate; decreased pulse pressure, blood pressure, systemic vascular resistance, central venous pressure, and pulmonary artery wedge pressure; normal or elevated pulmonary vascular resistance; and decreased, normal, or increased pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation.

While planning care, the nurse remembers which principle? In valvular _____, the valve opening is constricted and narrowed because the valve leaflets, or cusps, fail to open completely. A. Regurgitation B. Insufficiency C. Incompetence D. Stenosis

Stenosis

A 50-year-old male with a 30-year history of smoking was diagnosed with bronchogenic cancer. He developed edema and venous distention in the upper extremities and face. Which of the following diagnosis will the nurse observe on the chart? A. Thromboembolism B. Chronic venous insufficiency C. Deep vein thrombosis D. Superior vena cava syndrome (SVCS)

Superior vena cava syndrome (SVCS)

A 51-year-old male presents with recurrent chest pain on exertion. He is diagnosed with angina pectoris. When he asks what causes the pain, how should the nurse respond? The pain occurs when: A. The myocardial oxygen supply has fallen below demand. B. Myocardial stretch has exceeded the upper limits. C. Cardiac output has fallen below normal levels. D. The vagus nerve is stimulated.

The myocardial oxygen supply has fallen below demand

Which of the following findings in the patient with Raynaud disease would indicate a need for further teaching? A. The patient eats bananas twice a day. B. The patient smokes cigarettes. C. The patient takes calcium channel blockers. D. The patient wears mittens outside.

The patient smokes cigarettes

A 75-year-old female has been critically ill with multiple organ dysfunction syndrome (MODS) for longer than a week and has developed a severe oxygen supply and demand imbalance. The statement that best describes this imbalance is which of the following? A. The reserve has been exhausted, and the amount of oxygen consumed depends on the amount the circulation is able to deliver. B. Increased oxygen delivery to cells fails to meet decreased oxygen demands. C. The amount of oxygen consumed by cells depends only on the needs of cells, because there is oxygen in reserve. D. The situation results in supply-independent consumption.

The reserve has been exhausted, and the amount of oxygen consumed depends on the amount the circulation is able to deliver

A 60-year-old female had a myocardial infarction. She was brought to the hospital 30 minutes later. She survived, but now the nurse is providing care for impaired ventricular function because: A. The resulting ischemia leads to hypoxic injury and myocardial cell death. B. The cells become hypertrophic. C. There is too much stress on the heart. D. There is a temporary alteration in electrolyte balance.

The resulting ischemia leads to hypoxic injury and myocardial cell death

A 50-year-old obese male with hypertension and coronary artery disease visits a nutritionist for food counseling. He has an elevated level of low-density lipoprotein (LDL) and a low level of high-density lipoprotein (HDL). Which of the following should the nurse advise him to avoid? A. Trans fats B. Saturated fats C. Monounsaturated fats D. Polyunsaturated fats

Trans fats

A 32-year-old female presents with lower leg pain, with swelling and redness. While obtaining the patient's history, which finding could have caused her condition? A. Bacterial infection B. Heart valve damage C. Venous thrombus D. Atherosclerosis

Venous thrombus

A 65-year-old female presents to the emergency department reporting difficulty swallowing and shortness of breath. A CT scan would most likely reveal an aneurysm in the: A. Thoracic aorta B. Renal arteries C. Cerebral vessels D. Inferior vena cava

thoracic aorta

25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a. stool guaiac and bowel sounds. b. lung sounds and oxygenation status. c. serum creatinine and urinary output. d. serum bilirubin levels and skin color.

Correct Answer: B Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.

A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a. "Is there any family history of heart disease?" b. "Do you take aspirin on a daily basis?" c. "Can you describe the quality of your chest pain?" d. "What time did your chest pain begin?"

"What time did your chest pain begin?" Rationale: Fibrinolytic therapy should be started within 6 hours of the onset of the MI, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about fibrinolytic therapy.

A 40-year-old man with a history of IV drug use presents with cellulitis with multiple abscesses of the right upper extremity. His current weight is 70 kg (lean body weight). He rapidly develops worsening respiratory distress and hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shows a pH of 7.23, Paco2 of 58 torr, Pao2 of 60 torr, and an oxygen saturation of 88%. His ventila- tor settings are assist-control mode with a tidal vol- ume of 420 mL, respiratory rate of 16 breaths/min,positive end-expiratory pressure (PEEP) of 5 cm H2O, and Fio2 of 70%. His plateau pressure on the ventilator is 29 cm H2O. A chest radiograph shows bilateral interstitial infiltrates, and a 2-dimensional echocardiogram demonstrates normal left ventricular function. What ventilator adjustments should be made? (A) Change the ventilator mode to synchronized intermittent mandatory ventilation (B) Increase PEEP (C) Increase respiratory rate to 24 breaths/min (D) Increase tidal volume to 600 mL (E) Leave the ventilator settings unchanged

(B) Increase PEEP. The largest trial of a volume and pressure-limited strategy showed a 9% decrease in all-cause mortality in patients ventilated with tidal volumes of 6 mL/kg of estimated lean body weight as compared with a tidal volume of 12 mL/kg (target plateau pressure, < 30 cm H2O).3 Based on the results of this study, a strategy of using low tidal volume and high PEEP is recommended for mechanical ventilation of acute lung injury/ARDS patients.

Which of the following is true of vasopressin in septic shock? (A) Continuous infusion at low doses improves 28-day overall mortality (B) Continuous infusion at low doses improves mortality in patients with severe septic shock (C) Continuous infusion at low doses increases cardiac output (D) Continuous infusion at low doses reduces the catecholamine infusion requirement

(D) Continuous infusion at low doses reduces the catecholamine infusion requirement. Vasopressin is a peptide synthesi zed in the hypothalamus and released from the posterior pituitary. Vasopressin produces a wide range of physiologic effects, including blood pressure maintenance. Acting through vascular V1receptors, the endogenous hormone directly induces vasoconstriction in hypotensive patients but does not significantly alter vascular smooth muscle constriction in humans with normal blood pressure. Landry and colleagues8 demonstrated that patients with septic shock had inappropriately low levels of serum vasopressin compared with patients with cardiogenic shock, who had normal or elevated levels. In addition, they demonstrated that supplementing a low-dose infusion of vasopressin in septic shock patients allowed for the reduction or removal of the other catecholamine vasopressors. This was seen de- spite a reduction in cardiac output. Although these results were duplicated in subsequent studies, none evaluated outcomes such as length of stay or mortal- ity until recently. A randomized double-blind study comparing vasopressin versus norepinephrine for the treatment of septic shock demonstrated no dif- ference in 28-day mortality between the 2 treatment groups.9 Subgroup analysis of patients with severe septic shock, defined as requiring 15 μg/min of norepinephrine or its equivalent, also did not demonstrate a mortality benefit. However, patients with less severe septic shock (ie, requiring 5-15 μg/min of norepinephrine) experienced a trend toward lower mortality when treated with low-dose (0.01-0.03 U/min) vasopressin.

A 70-year-old man presents to the emergency de- partment with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. What is the first step in the initial management of this patient? (A) Antibiotic therapy (B) β-Blocker therapy to control heart rate (C) Intravenous (IV) fluid resuscitation (D) Supplemental oxygen and airway management (E) Vasopressor therapy with dopamine

(D) Supplemental oxygen and airway management. The initial evaluation of any critically ill patient in shock should include assessing and establishing an airway, evaluating breathing (which includes consideration of mechanical ventilator support), and restoring adequate circulation.2 Adequate oxygenation should be ensured with a goal of achieving an arterial oxygen saturation of 90% or greater.

Which of the following patients is an ideal candi- date for noninvasive positive pressure ventilation (NIPPV)? (A) A 30-year-old comatose woman suspected of drug overdose (B) A 55-year-old man with acute anterior wall myocardial infarction with cardiogenic shock and recurrent ventricular arrhythmias (C) A 60-year-old man with peritonitis requiring 2 vasopressors (D) A 65-year-old patient with a massive stroke and inability to protect airway (E) A 70-year-old alert patient with respiratory failure due to chronic obstructive pulmonary disease exacerbation

(E) A 70-year-old alert patient with respiratory failure due to chronic obstructive pulmonary disease exacerbation. NIPPV can be considered in carefully selected patients with sepsis. Patients with shock, altered mental status, or increased airway secretions should not be treated with NIPPV.4 Studies regarding the use of NIPPV in patients with sepsis-induced acute lung injury/ARDS are limited. In our experience, patients with normal mental status who are likely to recover within 48 to 72 hours seem to be good candidates for NIPPV.

A 52-year-old male is diagnosed with primary hypertension. He has no other health problems. Present treatment would cause the nurse to anticipate administering which drug to the patient? A. A beta-adrenergic agonist B. A calcium channel agonist C. An alpha-adrenergic agonist D. A diuretic

A diuretic

Which condition should cause the nurse to assess for high-output failure in a patient? A. Hypovolemia B. Hypothyroidism C. Metabolic alkalosis D. Anemia

Anemia

Which interventions should be used for anaphylactic shock (select all that apply)? a. Antibiotics b. Vasodilator c. Antihistamine d. Oxygen supplementation e. Colloid volume expansion f. Crystalloid volume expansion

Antihistamine, Oxygen supplementation, and Colloid volume expansion Rationale: Due to the massive vasodilation, release of vasoactive mediators, and increased in capillary permeability from the immediate reaction, fluid leaks from the vascular space into the interstitial space. By administering a colloid (which contain larger particles that do not penetrate the semipermable membrane), the large particles will stay intravascularly. Due to their smaller size particle composition, a crystalloid would not stay intravascularly and leak interstitially.

A 72-year-old female has a history of hypertension and atherosclerosis. An echocardiogram reveals backflow of blood into the left ventricle. Which of the following is the most likely diagnosis documented on the chart? A. Mitral regurgitation B. Mitral stenosis C. Aortic regurgitation D. Aortic stenosis

Aortic regurgitation

Which of the following lab tests will the nurse check to help diagnose heart failure and provide insight into its severity? A. Renin level B. Potassium C. Brain natriuretic D. Troponin

Brain natriuretic

19. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for a. additional fluid replacement. b. antibiotic administration. c. infusion of a sympathomimetic drug. d. administration of increased oxygen.

Correct Answer: A Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.

21. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a. urine output of 0.5 ml/kg/hr. b. decreased peripheral edema. c. decreased CVP. d. oxygen saturation 90% or more.

Correct Answer: A Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.

15. The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a. urine output is 40 ml over the last hour. b. hemoglobin is within normal limits. c. CVP has decreased. d. mean arterial pressure (MAP) is 65 mm Hg.

Correct Answer: A Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.

12. All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first? a. Epinephrine (Adrenalin) b. Normal saline infusion c. Dexamethasone (Decadron) d. Diphenhydramine (Benadryl)

Correct Answer: A Rationale: Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones administered.

23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a. The cardiac output is elevated. b. The central venous pressure (CVP) is increased. c. The systemic vascular resistance (SVR) is high. d. The PAWP is high.

Correct Answer: A Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.

13. A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate a. administration of furosemide (Lasix) IV. b. titration of an epinephrine (Adrenalin) drip. c. administration of a normal saline bolus. d. assisting with endotracheal intubation.

Correct Answer: A Rationale: The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.

26. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes a. respiratory rate of 10 breaths/min. b. fixed urine specific gravity at 1.010. c. MAP of 55 mm Hg. d. 360-ml urine output in 8 hours.

Correct Answer: B Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient's respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.

22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first? a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. b. Give normal saline IV at 500 ml/hr. c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg. d. Infuse drotrecogin- (Xigris) 24 mcg/kg.

Correct Answer: B Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions are also appropriate and should be initiated quickly as well.

17. Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the a. patient's heart rate is less than 100. b. patient has received adequate fluid replacement. c. patient's urine output is within normal range. d. patient is not receiving other sympathomimetic drugs.

Correct Answer: B Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion. A patient with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so these values are not contraindications to vasoconstrictor therapy. Patients may receive other sympathomimetic drugs concurrently with Levophed.

4. While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a. cold, mottled extremities. b. restlessness and apprehension. c. a heart rate of 120 and cool, clammy skin. d. systolic BP less than 90 mm Hg.

Correct Answer: B Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.

6. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a. Insert two 14-gauge IV catheters. b. Administer oxygen at 100% per non-rebreather mask. c. Place the patient on continuous cardiac monitor. d. Draw blood to type and crossmatch for transfusions.

Correct Answer: B Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.

11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a. Administer all medications through the patient's indwelling central line. b. Place the patient in a private room. c. Restrict the patient to foods that have been well-cooked or processed. d. Insert a nasogastric (NG) tube for enteral feeding.

Correct Answer: B Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.

8. The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include a. pH 7.48, PaCO2 33 mm Hg. b. pH 7.33, PaCO2 30 mm Hg. c. pH 7.41, PaCO2 50 mm Hg. d. pH 7.38, PaCO2 45 mm Hg.

Correct Answer: B Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.

7. A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a. cool, clammy skin. b. shortness of breath. c. heart rate of 48 beats/min d. BP of 82/40 mm Hg.

Correct Answer: C Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.

14. The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a. a liter of lactated Ringer's solution. b. 500 ml of 5% albumin. c. two 14-gauge IV catheters. d. a retention catheter.

Correct Answer: C Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters would take priority.

18. When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the a. systolic BP increases to greater than 100 mm Hg. b. cardiac monitor shows sinus rhythm at 96 beats/min. c. PAWP drops to normal range. d. troponin and creatine kinase levels decrease.

Correct Answer: C Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left ventricle, normalization of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could occur with dobutamine infusion even if patient tissue perfusion was not improved. Troponin and creatine kinase (CK) levels are indicators of cardiac cellular death and are not used as indicators of improved tissue perfusion.

27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. BP 88/56 mm Hg b. Apical pulse 110 beats/min c. Urine output 15 ml for 2 hours d. Arterial oxygen saturation 90%

Correct Answer: C Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

9. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left-forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. The patient has an apical pulse rate of 58 beats/min. b. The patient's urine output has been 28 ml over the last hour. c. The patient's IV infusion site is cool and pale. d. The patient has warm, dry skin on the extremities.

Correct Answer: C Rationale: The coldness and pallor at the infusion site suggest extravasation of the Neo-Synephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-ml output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin indicates that the patient is in early neurogenic shock.

24. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS? a. The patient has crackles throughout both lung fields. b. The patient complains of 8/10 crushing chest pain. c. The patient has an elevated ammonia level and confusion. d. The patient has cool extremities and weak pedal pulses.

Correct Answer: C Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.

3. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.

Correct Answer: C Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.

10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).

Correct Answer: C Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.

Correct Answer: D Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.

20. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to a. arrange for the hospital pastoral care staff to visit the patient. b. ask the health care provider to prescribe a sedative drug for the patient. c. leave the patient alone with family members whenever possible. d. place the patient's call bell where it can be easily reached.

Correct Answer: D Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient's anxiety about dying.

2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the a. progressive stage of septic shock. b. compensatory stage of diabetic shock. c. refractory stage of cardiogenic shock. d. progressive stage of hypovolemic shock.

Correct Answer: D Rationale: The patient's history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient's temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient's neurologic status is not consistent with refractory shock.

A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate. This patient's condition can best be defined as which of the following? (A) Multi-organ dysfunction syndrome (MODS) (B) Sepsis (C) Septic shock (D) Severe sepsis (E) Systemic inflammatory response syndrome (SIRS)

D) Severe sepsis. The patient fulfills criteria for severe sepsis, defined as sepsis with evidence of organ dysfunction, hypoperfusion, or hypotension. SIRS is defined as an inflammatory response to insult manifested by 2 of the following: temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min, and white blood cell count greater that 12 × 103/μL, less than 4 × 103/μL, or 10% bands. A diagnosis of sepsis is given if infec- tion is present in addition to meeting criteria for SIRS. Septic shock includes sepsis-induced hypotension (despite fluid resuscitation) along with evidence of hypoperfusion. MODS is the presence of altered organ function such that hemostasis cannot be maintained without intervention.1 This patient's lack of fluid resuscitation classifies him as having severe sepsis rather than septic shock.

A 59-year-old female is diagnosed with left ventricular failure. If a decrease in kidney perfusion occurs, the nurse knows this would ultimately cause: A. Decreased left ventricular preload B. Decreased cardiac oxygen demand C. Increased systemic vascular resistance D. Increased pulmonary capillary permeability

Increased systemic vascular resistance

One consequence of switching from aerobic to anaerobic cellular metabolism during shock states is: A. Decreased adenosine triphosphate (ATP) production B. Cellular dehydration C. Cellular alkalosis D. Free radical formation

Decreased adenosine triphosphate (ATP) production

A 50-year-old male was admitted to the intensive care unit with a diagnosis of acute myocardial infarction (MI). He is being treated for shock. His cardiopulmonary symptoms include low blood pressure, tachycardia, and tachypnea. His skin is pale and cool. The primary cause of his shock is most likely: A. Decreased cardiac contractility B. Rapid heart rate C. Increased capillary permeability D. Decreased afterload due to vasodilation

Decreased cardiac contractibility

When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a- Increased serum albumin b- Decreased respiratory compliance c- Increased gastrointestinal (GI) motility d- Decreased blood urea nitrogen (BUN)/creatinine ratio

Decreased respiratory compliance Rationale: Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply): a. dobutamine to increase myocardial contractility. b. vasopressors to increase systemic vascular resistance. c. circulatory assist devices such as an intraaortic balloon pump. d. corticosteroids to stabilize the cell wall in the infarcted myocardium. e. Trendelenburg positioning to facilitate venous return and increase preload.

Dobutamine to increase myocardial contractility and Circulatory assist devices such as an intraaortic balloon pump. Rationale: Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device.

Which of the following is an indication for using corticosteroids in septic shock? (A) Acute respiratory distress syndrome (ARDS) (B) Necrotizing pneumonia (C) Peritonitis (D) Sepsis responding well to fluid resuscitation (E) Vasopressor-dependent septic shock

E) Vasopressor-dependent septic shock. An inappropriate cortisol response is not uncommon in patients with septic shock. Low-dose IV corticosteroids (hydrocortisone 200-300 mg/day) are recommended

When a person is in shock, a nurse remembers impairment in cellular metabolism is caused by: A. Free radical formation B. Lack of nervous or endocrine stimulation C. Inadequate tissue perfusion D. Release of toxic substances

Inadequate tissue perfusion

What laboratory finding fits with a medical diagnosis of cardiogenic shock? A. Decreased liver enzymes B. Increased white blood cells C. Decreased red blood cells, hemoglobin, and hematocrit D. Increased blood urea nitrogen (BUN) and serum creatinine levels

Increased blood urea nitrogen (BUN) and serum creatinine levels

What laboratory finding fits with a medical diagnosis of cardiogenic shock? a-Decreased liver enzymes b-Increased white blood cells c-Decreased red blood cells, hemoglobin, and hematocrit d-Increased blood urea nitrogen (BUN) and serum creatinine levels

Increased blood urea nitrogen (BUN) and serum creatinine levels Rationale: The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels do not typically 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 a patient. What is a priority nursing diagnosis? A. Acute pain B. Impaired tissue integrity C. Decreased cardiac output D. Ineffective tissue perfusion

Ineffective tissue perfusion

When caring for a patient in acute septic shock, what should the nurse anticipate? a- Infusing large amounts of IV fluids b- Administering osmotic and/or loop diuretics c- Administering IV diphenhydramine (Benadryl) d- Assisting with insertion of a ventricular assist device (VAD)

Infusing large amounts of IV fluids Rationale: 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. VADs are useful for cardiogenic shock not septic shock. Diphenhydramine (Benadryl) may be used for anaphylactic shock but would not be helpful with septic shock.

The nurse is caring for a 29-year-old man who was admitted a week ago with multiple rib fractures, a pulmonary contusion, and a left femur fracture from a motor vehicle crash. After the attending physician tells the family that the patient has developed sepsis, the family members have many questions. Which information should the nurse include in explaining the early stage of sepsis? a-Antibiotics are not useful once an infection has progressed to sepsis. b-Weaning the patient away from the ventilator is the top priority in sepsis. c-Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d-The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. Rationale: Patients with sepsis may be normovolemic but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Addititonal respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.

Which characteristic changes should the nurse keep in mind while caring for a patient with left heart failure? As left heart failure progresses: A. Left end-diastolic volume decreases. B. Pulmonary vascular resistance decreases. C. Left ventricular preload increases. D. Systemic vascular resistance decreases.

Left ventricular preload increases

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

Level of consciousness, urine output, and skin color and temperature. Rationale: Adequate tissue perfusion in a patient with multiple-organ dysfunction syndrome is assessed by the level of consciousness, urine output, capillary refill, peripheral sensation, skin color, extremity skin temperature, and peripheral pulses.

A 75-year-old obese female presents to her primary care provider reporting edema in the lower extremities. Physical exam reveals that she has varicose veins. Upon performing the history, which of the following is a possible cause for the varicose veins? A. Trauma to the deep veins B. Long periods of standing C. Extreme exercise D. Ischemia

Long periods of standing

A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit? A. Low blood pressure, tachycardia, generalized edema B. Severe respiratory distress, jugular venous distention, chest pain C. Reduced cardiac output, increased systemic vascular resistance, moist cough D. Bradycardia, palpitations, confusion, truncal rash

Low blood pressure, tachycardia, generalized edema

Which organ should the nurse monitor closely since it is often the first to fail in patients with multiple organ dysfunction syndrome (MODS)? A. Pancreas B. Heart C. Liver D. Lungs

Lungs

A staff member asks a nurse what foam cells are. What is the nurse's best response? Foam cells in a fatty streak are: A. Macrophages that engulf low-density lipoprotein (LDL) B. Deposited adipose cells C. Lipid-laden mast cells D. Injured neutrophils

Macrophages that engulf low-density lipoprotein (LDL)

The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? a-Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds b-Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin c-PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites d-Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL

PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites Rationale: Severe hypoxemia, lactic acidosis, and bleeding are clinical manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are clinical manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold/ clammy skin, agitation, tachypnea, and increased serum creatinine are clinical manifestations of the progressive stage of shock.

A 65-year-old male with a history of untreated hypertension is now experiencing left heart failure. A nurse recalls his untreated hypertension led to: A. Ventricular dilation and wall thinning B. Myocardial hypertrophy and ventricular remodeling C. Inhibition of renin and aldosterone D. Alterations in alpha and beta receptor function

Myocardial hypertrophy and ventricular remodeling

A 75-year-old male has severe chest pain and dials 911. Lab tests at the hospital reveal elevated levels of cardiac troponins I and T. Based upon the lab findings, the nurse suspects which of the following has occurred? A. Orthostatic hypotension B. Varicose veins C. Myocardial infarction (MI) D. Raynaud disease

Myocardial infarction (MI)

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.

Neurogenic shock from massive vasodilation Rationale: Neurogenic shock results in massive vasodilation without compensation as a result of the loss of sympathetic nervous system vasoconstrictor tone. Massive vasodilation leads to a pooling of blood in the blood vessels, tissue hypoperfusion, and, ultimately, impaired cellular metabolism. Clinical manifestations of neurogenic shock are hypotension (from the massive vasodilation) and bradycardia (from unopposed parasympathetic stimulation).

Following coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery to repair the leak. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient assessment is the most important for planning nursing care? a- Cardiac index (CI) 5 L/min/m2 b-Central venous pressure 8 mm Hg c-Mean arterial pressure (MAP) 86 mm Hg d-Pulmonary artery pressure (PAP) 28/14 mm Hg

Pulmonary artery pressure (PAP) 28/14 mm Hg Rationale: Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be due to the MI. The CI, CVP, and MAP readings are normal.

A 64-year-old woman is admitted to the emergency department vomiting bright red blood. The patient's vital signs are blood pressure 78/58 mm Hg, pulse 124 beats/minute, respirations 28 breaths/minute, and temperature 97.2° F (36.2° C). Which physician order should the nurse complete first? a-Obtain a 12-lead ECG and arterial blood gases. b-Rapidly administer 1000 mL normal saline solution IV. c-Administer norepinephrine (Levophed) by continuous IV infusion. d-Carefully insert a nasogastric tube and an indwelling bladder catheter.

Rapidly administer 1000 mL normal saline solution IV. Rationale: Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be initiated after fluid resuscitation is initiated.

A nurse takes an adult patient's blood pressure and determines it to be normal. What reading did the nurse obtain? A. Systolic pressure greater than 140 mm Hg and a diastolic pressure of 100 mm Hg B. Systolic pressure between 140 mm Hg and 150 mm Hg C. Systolic pressure less than 100 mm Hg regardless of diastolic pressure D. Systolic pressure less than 120 mm Hg and diastolic pressure less than 80 mm Hg

Systolic pressure less than 120 mm Hg and diastolic pressure less than 80 mm Hg

Many valvular stenosis and regurgitation disorders in adults have a common etiology. Which of the following conditions should alert the nurse that the patient may have both types of valve dysfunction? A. Heart failure B. Connective tissue disorders C. Syphilis infection D. Rheumatic fever or heart disease

Rheumatic fever or heart disease

Which patient is most prone to multiple organ dysfunction syndrome (MODS)? In a patient with: A. Autoimmune disease B. Septic shock C. Myocardial infarction (MI) D. Pulmonary disease

Septic shock

A 72-year-old female has a history of right heart failure caused by a right ventricular myocardial infarction. Which of the following symptoms are specifically related to her right heart failure? A. Hypertension B. Decreased urine output C. Dyspnea upon exertion D. Significant edema to both lower legs and feet

Significant edema to both lower legs and feet

A 52-year-old male presents with pooling of blood in the veins of the lower extremities and edema. The diagnosis is chronic venous insufficiency, and an expected assessment finding of this disorder is: A. Edema above the knee B. Gangrene C. Deep vein thrombus formation D. Skin hyperpigmentation

Skin hyperpigmentation

A 56-year-old male is diagnosed with coronary artery disease. Which of the following modifiable risk factors would the nurse suggest the patient change? A. Eating meat B. Living arrangements C. Drinking tomato juice D. Smoking cigarettes

Smoking cigarettes

When a nurse checks the patient for orthostatic hypotension, what did the nurse have the patient do? A. Eat B. Physical exertion C. Lie down D. Stand up

Stand up

What factors make a patient prone to neurogenic shock? Neurogenic shock can be caused by any factor that inhibits the: A. Thalamus B. Parasympathetic nervous system C. Somatic nervous system D. Sympathetic nervous system

Sympathetic nervous system

A 68-year-old female is experiencing left heart failure. Physical exam reveals elevated blood pressure. The nurse understands this is most likely caused by: A. Sympathetic nervous system compensation for decreased cardiac output B. Diastolic dysfunction C. Stress hormones promoting increased cardiac contractility D. Cardiotoxic effects of catecholamines and angiotensin

Sympathetic nervous system compensation for decreased cardiac output

A 50-year-old male is diagnosed with orthostatic hypotension. Which of the following symptoms would he most likely experience? A. Syncope and fainting B. Nausea and vomiting C. Chest pain and palpitations D. Headache and blurred vision

Syncope and fainting

A 27-year-old male is admitted to a neurologic unit with a complete C-5 spinal cord transection. On initial assessment, he is bradycardic, hypotensive, and hyperventilating. He appears to be going into shock. The most likely mechanism of his shock is: A. Vasodilation caused by gram-negative bacterial infection B. Vasodilation caused by a decrease in sympathetic stimulation C. Hypovolemia caused by evaporative fluid losses D. Hypovolemia caused by blood loss Reset Selection

Vasodilation caused by a decrease in sympathetic stimulation