Shock Q's

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. A. Distended neck veins B. Bradycardia C. Decreased blood pressure D. Shortness of breath E. Crackles in the lung fields

A. Distended neck veins D. Shortness of breath E. Crackles in the lung fields

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: A. Jugular venous distention B. Vesicular breath sounds C. Positive increase in the fluid balance ratio D. Decreased pulse rate to 110 beats/minute

A. Jugular venous distention

Which type of shock occurs from an antigen-antibody response? Septic Anaphylactic Neurogenic Cardiogenic

Anaphylactic

Which of the following clinical manifestations occur in cardiogenic shock? A. Quick capillary refill B. Skin is dry C. Blood pressure falls D. Urine output increases

C. Blood pressure falls

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.) A. Increased intravascular volume B. Activation of the inflammatory response C. Hypoperfusion of tissues D.Must produce energy through anaerobic metabolism E. Increase in cellular Activity

B. Activation of the inflammatory response C. Hypoperfusion of tissues D.Must produce energy through anaerobic metabolism

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A. Low heart rate B. Elevated blood pressure C. Subnormal temperature D. Rapid respiration

B. Elevated blood pressure

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows: Na + 147 mEq/L K + 3.0 mEq/L Cl - 112 mEq/L Mg ++ 2.3 mg/dL Ca ++ 1.5 mg/dL Which of the following is consistent with the client's findings? A. Hypernatremia B. Hypokalemia C. Hyperchloremia D. Hypophosphatemia

B. Hypokalemia Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias

A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as A. Hypovolemic B. Neurogenic C. Progressive D. Compensatory

B. Neurogenic

The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? A. Neurogenic B. Septic C. Cardiogenic D. Anaphylactic

B. Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures.

Which of the following would be a pulse pressure indicative of shock? A. 130/90 B. 120/90 C. 90/70 D. 100/60

C. 90/70

The nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? A. It causes respiratory distress syndrome. B. It begins when peripheral blood flow is inadequate. C. It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. D.It is a component of any trauma.

C. It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.

The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis

C. Metabolic acidosis

A 17-year-old-male 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? A. Anaphylactic shock B. Hypovolemic shock C. Neurogenic shock D.Septic shock

C. Neurogenic 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? A. Neurogenic B. Anaphylactic C. Septic D. Cardiogenic

C. Septic 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.

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family? A. The client has lost too much blood. B. The client is brain dead. C. The client is not responding to medical interventions. D. The client has given up.

C. The client is not responding to medical interventions.

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? A. 0.9% sodium chloride B. Albumin C. Dextran D. Lactated Ringer's

D. Lactated Ringer's

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? A. Respiratory acidosis B.Respiratory alkalosis C.Metabolic acidosis D.Metabolic alkalosis

D. Metabolic alkalosis The most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? A. Minimal urine output of 50 mL per hour B. Minimal urine output of 10 mL per hour C. Minimal intake of 2 liters per day D. Minimal intake of 1.5 liters per day

D. Minimal intake of 1.5 liters per day