Chapter 17: Caring for Clients in Shock
A client is believed to be in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse?
"The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them." Explanation: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided—throughout the patient's care—for the family to see, touch, and talk to the patient. However, the determination that the client is in the irreversible stage of shock can only be made retrospectively, when the client has failed to recover, so the health care team will continue to attempt interventions, possibly with experimental treatments. The engagement of a palliative care specialist and of the ethics committee may be helpful.
A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? -165 mEq/L -130 mEq/L -145 mEq/L -110 mEq/L
165 mEq/L Explanation: The normal sodium level is 135- 145 mEq/L (135-145 mmol/L). In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/kg (300 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected.
An average, healthy infant should have what percentage of interstitial body fluid? 4% 10% 15% 25%
25% Explanation: Extracellular fluid includes the water between cells (interstitial fluid) and in the plasma (serum) portion of blood (intravascular fluid). The body weight of a healthy infant is 77% water, with the following percentages: 4% intravascular, 25% interstitial, and 48% intracellular.
The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) -Crackles -Respirations <15 breaths/min -Compensatory respiratory acidosis -Lethargy and mental confusion -A heart rate >100 bpm
A heart rate >100 bpm Crackles Lethargy and mental confusion In compensatory shock, the heart rate is >100 bpm, the patient experiences lethargy and mental confusion, respirations are >20 breaths/min (not <15), and respiratory alkalosis is present (not respiratory acidosis). Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow. Crackles are heard over the lung fields.
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: -A myocardial infarction. -Cardiomyopathies. -Arrhythmias. -Valvular damage.
A myocardial infarction. Explanation: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: -Cardiomyopathies. -Valvular damage. -A myocardial infarction. -Arrhythmias.
A myocardial infarction. Explanation: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.
A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? -Obtain the name and information of the allergic substance. -Call 911. -Obtain a health history. -Administer an epinephrine injection as ordered by the health care provider.
Administer an epinephrine injection as ordered by the health care provider. Explanation: The key words in the question are "increasing symptoms." The first action of the nurse is to administer an epinephrine injection to abort the rapidly increasing symptoms. Next, the nurse will call 911.
The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? -Administer recombinant human activated protein C (rhAPC) as prescribed. -Initiate enteral feedings as prescribed. -Administer norepinephrine as prescribed. -Begin a continuous IV infusion of insulin per protocol.
Administer norepinephrine as prescribed. Explanation: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.
Which colloid is expensive but rapidly expands plasma volume? -Albumin -Hypertonic saline -Lactated Ringer solution -Dextran
Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.
The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention? Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock Reviewing the cause of shock and prioritizing the client's psychosocial needs Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
Assessing and understanding shock and the significant changes in assessment data to guide the plan of care Explanation: Nursing care of clients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of clients in shock; thus, suspecting that a client may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.
The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock? -Hypertension -Bradycardia -Cool, moist skin -Signs of sympathetic stimulation
Bradycardia Explanation: In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.
The nurse is caring for a client in metabolic alkalosis. The client has an NG tube set to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication prescriptions? -Maalox -Potassium chloride elixir -Cimetidine -Furosemide
Cimetidine Explanation: H2 receptor antagonists, such as cimetidine, reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a client in metabolic alkalosis. KCl would only be given if the client were hypokalemic, which is not stated in the scenario. Furosemide would only be given if the client were fluid overloaded, which is not stated in the scenario.
The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: -A systolic blood pressure of 75 mm Hg. -A heart rate of 140. -Crackles and shallow breathing. -Cold, clammy skin and tachycardia.
Cold, clammy skin and tachycardia. Explanation: In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.
A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care? -Communicate clearly and frequently with the client's family. -Taper down interventions slowly when the prognosis worsens. -Ask the client's family how they would prefer treatment to proceed. -Transfer the client to a subacute unit when recovery appears unlikely.
Communicate clearly and frequently with the client's family. Explanation: As it becomes obvious that the client is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the client's care for the family to see, touch, and talk to the client. However, the onus should not be placed on the family to guide care. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The client would not be transferred to a subacute unit.
A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care? -Transfer the client to a subacute unit when recovery appears unlikely. -Taper down interventions slowly when the prognosis worsens. -Ask the client's family how they would prefer treatment to proceed. Communicate clearly and frequently with the client's family.
Communicate clearly and frequently with the client's family. Explanation: As it becomes obvious that the client is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the client's care for the family to see, touch, and talk to the client. However, the onus should not be placed on the family to guide care. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The client would not be transferred to a subacute unit.
A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care? -Transfer the client to a subacute unit when recovery appears unlikely. -Taper down interventions slowly when the prognosis worsens. -Communicate clearly and frequently with the client's family. -Ask the client's family how they would prefer treatment to proceed.
Communicate clearly and frequently with the client's family. Explanation: As it becomes obvious that the client is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the client's care for the family to see, touch, and talk to the client. However, the onus should not be placed on the family to guide care. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The client would not be transferred to a subacute unit.
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? -Initial stage -Progressive stage -Compensatory stage -Irreversible stage
Compensatory stage Explanation: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? -Progressive stage -Initial stage -Irreversible stage -Compensatory stage
Compensatory stage Explanation: In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: -Constrict blood vessels in the cardiorespiratory system. -Relax the bronchioles. -Decrease heart rate. -Vasodilate the skeletal muscles.
Constrict blood vessels in the cardiorespiratory system. Explanation: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: -Relax the bronchioles. -Vasodilate the skeletal muscles. -Constrict blood vessels in the cardiorespiratory system. -Decrease heart rate.
Constrict blood vessels in the cardiorespiratory system. Explanation: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.
A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: -Relax the bronchioles. -Vasodilate the skeletal muscles. -Decrease heart rate. -Constrict blood vessels in the cardiorespiratory system.
Constrict blood vessels in the cardiorespiratory system. Explanation: Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.
A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence. The nurse should increase oral (PO) fluid intake, maintain prone position, and obtain the lactate level. Interventions administer oxygen therapy monitor temperature Your selection:
Correct response: Explanation: The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.
The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock? -Decreased urinary output -Increased hunger -Increased capillary perfusion -Decreased thirst
Decreased urinary output Explanation: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.
An ICU nurse caring for a client experiencing distributive shock should know that the pooling of blood in the periphery leads to what pathophysiologic effect? Increased stroke volume Increased cardiac output Decreased venous return Decreased heart rate
Decreased venous return Explanation: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.
An ICU nurse caring for a client experiencing distributive shock should know that the pooling of blood in the periphery leads to what pathophysiologic effect? -Increased cardiac output -Decreased venous return -Decreased heart rate -Increased stroke volume
Decreased venous return Explanation: Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and, ultimately, decreased tissue perfusion. Heart rate increases in an attempt to meet the demands of the body.
Which of the following nursing interventions helps minimize the risk for hypothermia in a patient in shock? -Administer a tepid sponge bath -Administer prescribed adrenergic and bronchodilating drugs -Direct warming lights to the patient's body -Administer prescribed antipyretics
Direct warming lights to the patient's body Explanation: Directing warming lights to the client's body and keeping the patient's head covered with a turban reduces heat loss. This helps minimize the risk of hypothermia related to hemorrhage. Administering antipyretics or a tepid sponge bath further reduces the body temperature and may cause complications. Adrenergic and bronchodilating drugs improve the potential for gas exchange but do not reduce the body temperature.
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stevens-Johnson syndrome from the administration of antibiotics Disseminated intravascular coagulation (DIC) Septicemia Stress ulcer
Disseminated intravascular coagulation (DIC) Explanation: Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.
One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will help to achieve what goal? Distinguish reduced renal blood flow from decreased renal function. Provide an effective treatment for hypertension-induced oliguria. Distinguish hyponatremia from hypernatremia. Evaluate pituitary gland function,
Distinguish reduced renal blood flow from decreased renal function. Explanation: If a client is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a client with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.
A client presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first? -IV infusion of normal saline -Diphenhydramine IV -Epinephrine intramuscularly -Albuterol nebulizer
Epinephrine intramuscularly Explanation: All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive action. IV Diphenhydramine is administered to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications such as albuterol may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability.
A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? -Shortness of breath -Cool, moist skin -HR, 120 bpm; BP, 88/58 mm Hg -HR, 48 bpm; BP, 90/60 mm Hg
HR, 48 bpm; BP, 90/60 mm Hg Explanation: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock.
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? -Pericardiocentesis -Intubation and mechanical ventilation -Administration of oxygen via venture mask -Thoracotomy with chest tube insertion
Intubation and mechanical ventilation Explanation: Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Pericardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered? -Nipride -Dobutrex -Methotrexate -Levophed
Levophed Explanation: The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.
A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? -Morphine -Codeine -Hydromorphone -Meperidine
Morphine Explanation: If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption.
Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? -Anaphylactic -Neurogenic -Cardiogenic -Septic
Neurogenic Explanation: The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.
A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing? -Anaphylactic shock -Neurogenic -Hypovolemic shock -Septic shock
Neurogenic shock Explanation: Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing? -Septic shock -Hypovolemic shock -Anaphylactic shock -Neurogenic shock
Neurogenic shock Explanation: Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, "Wouldn't sterile water be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? When the client is severely dehydrated resulting in neurologic signs and symptoms Never, because it rapidly enters red blood cells, causing them to rupture. When the client is in excess of calcium and/or magnesium ions When a client's fluid volume deficit is due to acute or chronic kidney disease
Never, because it rapidly enters red blood cells, causing them to rupture. Explanation: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated? -Performing frequent oral care -Maintaining the client in a supine position -Suctioning the client every 15 minutes unless contraindicated -Administering prophylactic antibiotics, as prescribed
Performing frequent oral care Explanation: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.
When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? Compensatory Refractory Progressive Irreversible
Progressive Explanation: In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.
When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? -Irreversible -Progressive -Refractory -Compensatory
Progressive Explanation: In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in? -Initial -Progressive -Irreversible -Compensatory
Progressive Explanation: In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.
The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in? -Irreversible -Initial -Progressive -Compensatory
Progressive Explanation: In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock? Initiate total parenteral nutrition (TPN) Perform passive range-of-motion exercises unless contraindicated Remove invasive devices as soon as they are no longer needed Apply an antibiotic ointment to the client's mucous membranes, as ordered.
Remove invasive devices as soon as they are no longer needed Explanation: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.
The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS) with likely progression to the irreversible stage. The nurse's plan of care should include which of the following interventions? Discussing organ donation on several different occasions Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months Promoting communication with the client and family along with addressing end-of-life issues Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good Exit quiz
Promoting communication with the client and family along with addressing end-of-life issues Explanation: Promoting communication with the client and family is a critical role of the nurse with a client in the irreversible stage of progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the client's wishes. Many cases of MODS result in death and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then the family should be given time to discuss and return to the health care providers with an answer following the death of the client.
A client has been admitted to the intensive care unit (ICU) after a motor vehicle crash. Which nursing intervention(s) will help minimize this client's risk for developing hypothermia as a result of shock? Select all that apply. -Administer prescribed adrenergic drugs. -Administer prescribed antipyretics. -Keep the client's head covered with a turban. -Provide direct warming lights to the client's body. -Warm IV solutions and blood products.
Provide direct warming lights to the client's body. Keep the client's head covered with a turban. Warm IV solutions and blood products. Explanation: Warming the environment and using a warming blanket or direct warming lights will help raise body temperature. Keeping the client's head covered with a turban made of stockinette or other material reduces heat loss. Warmed infusions raise the temperature of tissues where they are circulated. Although administering adrenergic and antipyretic drugs are not nursing interventions that minimize the client's risk for developing hypothermia as a result of shock, they may be given as treatment for the client with shock.
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? -Anaphylactic -Septic -Neurogenic -Cardiogenic
Septic Explanation: In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.
The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock? -Bradycardia -Elevated mean arterial pressure -Elevated systolic blood pressure -Shallow, rapid respirations
Shallow, rapid respirations Explanation: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock; mean arterial pressure is less than 65 mm Hg. Bradycardia occurs in neurogenic shock, but other states of shock are normally accompanied by tachycardia.
The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock? -Shallow, rapid respirations -Elevated mean arterial pressure -Bradycardia -Elevated systolic blood pressure
Shallow, rapid respirations Explanation: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock; mean arterial pressure is less than 65 mm Hg. Bradycardia occurs in neurogenic shock, but other states of shock are normally accompanied by tachycardia.
The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines? -T3 and T4 -Myoglobin and CK-MB -Sodium and glucose levels -BUN and creatinine
Sodium and glucose levels Explanation: In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.
When a client is in the compensatory stage of shock, which symptom occurs? -Tachycardia -Bradycardia -Respiratory acidosis -Urine output of 45 mL/hr
Tachycardia Explanation: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
When a client is in the compensatory stage of shock, which symptom occurs? -Tachycardia -Respiratory acidosis -Bradycardia -Urine output of 45 mL/hr
Tachycardia Explanation: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
When a client is in the compensatory stage of shock, which symptom occurs? -Urine output of 45 mL/hr -Respiratory acidosis -Bradycardia -Tachycardia
Tachycardia Explanation: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
When a client is in the compensatory stage of shock, which symptom occurs? -Bradycardia -Respiratory acidosis -Urine output of 45 cc/hour -Tachycardia
Tachycardia Explanation: The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way? -By a gravity infusion IV set -Mixed with parenteral feedings to balance osmosis -By IV push for rapid onset of action -Through a central venous line
Through a central venous line Explanation: Whenever possible, vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.
The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way? -Mixed with parenteral feedings to balance osmosis -By a gravity infusion IV set -By IV push for rapid onset of action -Through a central venous line
Through a central venous line Explanation: Whenever possible, vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? -To limit stroke volume and cardiac output -To maintain adequate mean arterial pressure (MAP) -To prevent pulmonary and peripheral edema -To prevent the formation of infarcts of emboli
To maintain adequate mean arterial pressure (MAP) Explanation: Vasoactive medications can be administered in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? -To prevent pulmonary and peripheral edema -To prevent the formation of infarcts of emboli -To maintain adequate mean arterial pressure (MAP) -To limit stroke volume and cardiac output
To maintain adequate mean arterial pressure (MAP) Explanation: Vasoactive medications can be administered in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal? -Treat the oxygenation needs of the heart muscle -Limit further myocardial damage -Improve the heart's pumping mechanism -Preserve the healthy myocardium
Treat the oxygenation needs of the heart muscle Explanation: As with all forms of shock, the underlying cause of cardiogenic shock must be corrected. It is necessary first to treat the oxygenation needs of the heart muscle to ensure its continued ability to pump blood to other organs.
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Explanation: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant intervention
Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Explanation: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? -Administer prophylactic antibiotics for all patients at risk. -Use strict hand hygiene techniques. -Insert indwelling catheters for incontinent patients. -Have patients wear masks in the health care facility.
Use strict hand hygiene techniques. Explanation: The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques. Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections.
A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. -H2 blockers -proton pump inhibitors -proteases -promotility agents -antacids
antacids H2 blockers proton pump inhibitors Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, H2 blockers [e.g., famotidine (Pepcid)], and proton pump inhibitors [e.g., lansoprazole (Prevacid), esomeprazole magnesium (Nexium)] are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite.
A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? -heart rate <100 bpm -PaCO2 >45 mm Hg -metabolic acidosis -compensatory respiratory alkalosis
compensatory respiratory alkalosis Explanation: In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid. PaCO2 >45 mm Hg, is an expected finding in the progressive state of shock.
A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? -decompensation stage -irreversible stage -compensation stage -cardiogenic shock
decompensation stage Explanation: Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.
What is the major clinical use of dobutamine? -increase cardiac output. -treat hypertension. -treat hypotension. -prevent sinus bradycardia.
increase cardiac output. Explanation: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin. Complete the following sentence by choosing from the lists of options. The client is at the highest risk for developing as evidenced by altered mental ion
septic shock as evidenced by chest pain Shock is a life-threatening physiologic condition in which there is inadequate blood flow to tissues and cells of the body. Different types of shock states exist, with septic shock having the highest mortality due to the likelihood of multiple organ system dysfunction. A client who is critically ill with pneumonia is at risk for septic shock. Septic shock is a subset of sepsis in which underlying circulatory and cellular metabolic abnormalities are profound enough to substantially increase mortality. Septic shock is evidenced by the following: a respiratory rate greater than or equal to 22 breaths/min; altered mentation; and a systolic blood pressure (BP) less than or equal to 100 mm Hg. The nurse should notify the client's health care provider (HCP) when these symptoms occur with infection because they are indicative of septic shock. Based on the clinical presentation; increased leukocyte count; fever; and warm, flushed skin indicating increased perfusion, this client who is critically ill with pneumonia is at risk for sepsis and, therefore, septic shock, not hypovolemic or cardiogenic shock. Clients who experience a loss of blood volume are at risk for hypovolemic shock, whereas those who experience an acute myocardial infarction (MI) are at risk for cardiogenic shock. Because the client is presenting with warm, flushed skin, the nurse would not expect to see decreased urine output at this time. A clinical manifestation indicative of cardiogenic shock is angina (i.e., chest pain), which is not seen in septic shock.
The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of the client -who has had an overdose of opioids. -who has lost blood during birth. -who has had severe allergic reaction to a bee sting. -with an overwhelming bacterial infection.
with an overwhelming bacterial infection. Explanation: Unlike other forms of shock, clients with septic shock have an elevated leukocyte count and initially manifest fever accompanied by warm, flushed skin and a rapid, bounding pulse. Therefore, the client with an overwhelming bacterial infection is most likely to exhibit these symptoms. Extreme loss of blood causes hypovolemic shock, an overdose of opioids causes neurogenic shock, and a severe allergic reaction causes anaphylactic shock.
