Chapter 34: Shock, Sepsis, and Multiple-Organ Dysfunction Syndrome Urden: Critical Care Nursing, 8th Edition

19. The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin

ANS: C Tumor necrosis factor-á (TNF-á, also known as cachectin) is a polypeptide that is released from macrophages and lymphocytes in response to endotoxin, tissue injury, viral agents, and interleukins. When present in excessive amounts, TNF-á causes widespread destruction in most organ systems and is responsible for the pathophysiologic changes in systemic inflammatory response syndrome (SIRS) and septic shock, including fever, hypotension, decreased organ perfusion, and increased capillary permeability. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 830 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

17. The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)

ANS: C When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 824 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

20. A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion

ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 830 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

2. The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia

ANS: A Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume. PTS: 1 DIF: Cognitive Level: Applying REF: p. 805 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

8. A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine

ANS: D Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators. PTS: 1 DIF: Cognitive Level: Applying REF: p. 814 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

4. The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system

ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 807 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

10. A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5

ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 821|Box 34-17 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

25. An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury

ANS: A Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 821 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

15. A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine

ANS: A Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

3. A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest. PTS: 1 DIF: Cognitive Level: Applying REF: p. 807 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

27. A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres

ANS: A Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 815 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

7. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility

ANS: A Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output. PTS: 1 DIF: Cognitive Level: Applying REF: p. 811|p. 813|Box 34-10 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

11. A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss

ANS: A The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 817 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential

ANS: A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 822 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

21. A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase

ANS: C Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism. PTS: 1 DIF: Cognitive Level: Applying REF: p. 832 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

3. The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone

ANS: A, C, D There is no evidence to support the use of low-dose dopamine to maintain urine output. An adrenocorticotropic hormone (ACTH) stimulation test should not be used to identify patients who need hydrocortisone. PTS: 1 DIF: Cognitive Level: Applying REF: p. 804|p. 821|Box 34-17 OBJ: Nursing Process Step: Planning TOP:

16. The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure

ANS: B According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level. 2. Obtain blood cultures prior to administration of antibiotics. 3. Administer broad spectrum antibiotics. 4. Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. PTS: 1 DIF: Cognitive Level: Applying REF: p. 821|Box 34-17 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

22. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume

ANS: B Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 833 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

12. A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs

ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions. PTS: 1 DIF: Cognitive Level: Applying REF: p. 822 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

26. The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.

ANS: B Hypermetabolism in systemic inflammatory response syndrome (SIRS) or multiple-organ dysfunction syndrome (MODS) results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 834 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

18. A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.

ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 823 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

1. A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.

ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 801 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

13. A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure

ANS: B Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 805 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

24. The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.

ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution. PTS: 1 DIF: Cognitive Level: Applying REF: p. 804 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

9. A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor

ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion. PTS: 1 DIF: Cognitive Level: Applying REF: p. 815 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

2. A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure

ANS: B, C, D Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 809|Box 34-7 OBJ: Nursing Process Step: Planning TOP: Shock MSC: NCLEX: Physiologic Integrity

6. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response

ANS: C Immunoglobulin E (IgE) is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs. PTS: 1 DIF: Cognitive Level: Applying REF: p. 811 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

23. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels

ANS: C Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 833 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

14. A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)

ANS: C Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

5. The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index

ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity