shock & multisystem failure

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?

norepinephrine (Levophed)

You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?

Restores blood pressure

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first?

100% oxygen via a nonrebreather mask

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin and bradycardia with hypotension. What type of shock is the nurse assessing?

neurogenic

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

70%

Which pulse pressure indicates shock?

90/70 mm HG; A narrowed or decreased pulse pressure is an early indicator of shock. A normal pulse pressure is 40 mm Hg

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

A continuous infusion of total parenteral nutrition; Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.

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.

The nurse is actively managing the intravenous fluid administration for a patient who has developed cardiogenic shock after a myocardial infarction. When performing this aspect of nursing care, what principle should guide the nurse's decision making?

Adequate fluid resuscitation must be balanced against the risk of fluid overload

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 norepinephrine as prescribed; 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.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?

Adrenergic drugs

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage?

Albumin

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

Brain; The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?

Distributive

When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?

Aorta

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

Aortic insufficiency

A medical-surgical nurse is aware that pulmonary embolism (PE) and tension pneumothorax are medical diagnoses that have the potential to result in shock. What commonality between these two health problems creates the potential for shock?

Both health problems involve an obstruction of normal blood flow

An understanding of the pathophysiologic rationale behind shock is necessary for sound nursing practice. Which of the following statements best describes the pathophysiology of shock?

Cells lack an adequate blood supply and are deprived of oxygen and nutrients.

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?

Circulatory (distributive)

A client who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse

Consults with the physician about subsituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix); Pantoprazole tablets are not to be broken, crushed, or chewed. Lansoprazole is substituted for this medication. The nurse consults with the physician about substituting another proton pump inhibitor for pantoprazole. Enteral feedings are initiated at a slow rate to ensure adequate digestion. The nasogastric tube is measured from earlobe to xiphoid process and 6 inches are added to the length of the tube to be inserted. Placement of a PEG tube is not necessary at this time. The client is unstable. The tube is meant for long-term, not short-term, placement.

The nurse is admitting a patient with a diagnosis of a gastrointestinal bleed who is in the compensatory stage of shock. Which of the following is an early sign that accompanies compensatory shock?

Cool, clammy skin; In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patient's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client?

Decreased blood pressure

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is

Dextran; Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?

Diphenhydramine (Benadryl)

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?

Disseminated intravascular coagulation (DIC)

An older adult woman was admitted to the hospital for the treatment of a complicated urinary tract infection. Since admission the patient has developed urosepsis and failed to respond to treatment. The patient's most recent changes in condition are indicative of septic shock and she has been transferred to the critical care unit. What aspect of care will be prioritized in the woman's subsequent phase of treatment?

Eliminating the cause of the patient's infection; Current treatment of septic shock involves identification and elimination of the cause of infection and aggressive cardiopulmonary support. These actions are priorities over other aspects of care such as nutritional support, patient participation, and monitoring cognition, even though each of these interventions is valid and appropriate.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to

Encourage the family to touch and talk to the client; The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

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?

Epinephrine intramuscularly; 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 patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?

Epinephrine; Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when:

Fluid circulating in the blood vessels decreases.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

Head injury

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.)

Hypoperfusion of tissues Must produce energy through anaerobic metabolism Activation of the inflammatory response

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?

In the compensation stage, catecholamines are released; Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?

Increase the force of myocardial contraction

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?

Intubation and mechanical ventilation

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?

Irreversible

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

Lactated Ringer's; Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess

Lung sounds; Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the

Lungs; During MODS, the organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Maintain activity restriction to bedrest.

A patient in shock has been started on a dobutamine infusion in the intensive care unit. The nurse knows that the infusion rate will be constantly adjusted to maximize therapeutic effect. Changes to the infusion rate of this vasoactive medication will be primarily based on what assessment finding?

Mean arterial pressure (MAP)

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?

Modified Trendelenburg

A patient is being treated for septic shock. On assessment, the nurse notes an abnormal finding that is reported to the health care provider. Which of the following is most likely that finding?

SVO2 of 55%; Normal SVO2 values range from 60% to 80%. Lower values indicate inadequate tissue perfusion and the need for medical intervention.

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

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

Narrowed pulse pressure

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

Neurogenic shock

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?

Neurogenic shock

Which vasodilator medication is used in the treatment of shock?

Nitroglycerin

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula; In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation?

Pedal pulse stronger

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?

Progressive

The nurse is caring for a patient in the intensive care unit who is suffering from multiple organ dysfunction syndrome (MODS). What should the nurse's plan of care focus on?

Promoting communication with the patient and family along with addressing end-of-life issues

Morphine sulfate has which of the following effects on the body?

Reduces preload; In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).

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; 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.

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as

Sodium nitroprusside; Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock.

When a client is in the compensatory stage of shock, which symptom occurs?

Tachycardia; The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

A patient has been admitted to the emergency department with a massive gastrointestinal bleed and the team recognizes that hypovolemic shock is an imminent possibility. What assessment finding would suggest that the patient is deteriorating from a preshock state into shock?

The patient has crackles on chest auscultation; Adventitious breath sounds are associated with the shock (uncompensated) stage. In the preshock state, the patient may be confused (ie, not yet lethargic) and respiratory rate may be normal or near normal. As well, the patient is not yet acutely hypotensive in the preshock state.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy:

The right foot is cooler than the left foot.

When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications from shock. What does this require the nurse to do?

Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment and response.

A critical care nurse has provided care for several patients over the preceding months who were admitted to the unit with septic shock. The nurse has become aware that the incidence of septic shock is increasing. Which of the following actions has the greatest potential to reduce the incidence of septic shock?

Vigilant application of infection control procedures

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)

Vital signs Mental status Urinary output

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.

Vital signs Skin color Urine output Peripheral pulses; Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply.

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome