study Questions set for week 6

C (ANS: C Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.)

8. Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102 F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids

1 (Metabolic acidosis occurs due to impaired tissue perfusion, hypoxia, the shift to anaerobic metabolism which increases lactate levels, and renal dysfunction. Respiratory acidosis, respiratory alkalosis, and metabolic alkalosis have different indicators.)

(staes of shock) (late stage )rfractory) The the nurse knows that which acid-base imbalance occurs in multiple organ dysfunction syndrome (MODS) due to impaired tissue perfusion, hypoxia, and increased lactate levels? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

B (ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.)

. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L

A (Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities.)

1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as not assessable.

A (In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.)

11. A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance

A (The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not beat for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.))

14. The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. The action of the machine will improve blood supply to the damaged heart. b. The machine will beat for the damaged heart with every beat until it heals. c. The machine will help cleanse the blood of impurities that might damage the heart. d. The machine will remain in place until the patient is ready for a heart transplant.

c (ANS: C Hypovolemic results in a loss of circulating fluid volume. A decrease in circulating volume leads to a decrease in venous return, which results in a decrease in end-diastolic volume or preload.)

2. Hypovolemic shock that results from an internal shifting of fluid from the intravascular space to the extravascular space is known as a. absolute hypovolemia. b. distributive hypovolemia. c. relative hypovolemia. d. compensatory hypovolemia.

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.)

3. The nursing measure that can best enhance large volumes of fluid replacement in hypovolemic shock is a. insertion of a large-diameter peripheral intravenous catheter. b. positioning the patient in the Trendelenburg position. c. forcing at least 240 mL of fluid each hour. d. administering intravenous lines under pressure.

D (Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not within normal limits. A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.)

4. A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

A (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.)

4. The main cause of cardiogenic shock is a. an inability of the heart to pump blood forward. b. hypovolemia, resulting in decreased stroke volume. c. disruption of the conduction system when re-entry phenomenon occurs. d. an inability of the heart to respond to inotropic agents.

C (ANS: C The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringers solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.)

5. A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringers bolus d. Packed red blood cells

A (Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario)

9. The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a. Dobutamine (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) D.Sodium nitroprusside (Nipride)

2345 (Rationale 1: This patient is about to die. Family should be allowed as much time with the patient as possible, even if the rules are not followed. Rationale 2: Describing the patients appearance is important in this situation. Rationale 3: The family should be alerted to the fact that the patient is unconscious or otherwise unable to talk. Assuring them that their loved one will know they are there is comforting. Rationale 4: The family should be apprised of the patients appearance prior to visiting. Rationale 5: It is important to let the family know what comfort measures have been provided for their loved one. Global Rationale:)

A 20-year-old male was seriously wounded in a shooting incident and is not expected to survive the resulting hypovolemic shock. Which nursing statements to the family are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The rules allow only two visitors for 5 minutes. 2. Your sons color is very gray. 3. Your son will not be able to talk to you, but he will know you are there. 4. Your son has a big bandage around his head and his face is swollen and bruised. 5. We have given your son pain medication for his wounds.

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

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

ABCF

A nursing assessment of a patient with hypovolemic shock is most likely to reveal what assessment findings? Select all that apply. A) Tachycardia B) Oliguria C) Disoriented to time and place D) Diuresis E) Bradycardia F) Hypotension

2. (Cardiogenic shockOne of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension.)

A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of which condition? 1. A secondary MI 2. Cardiogenic shock 3. Pulmonary edema 4. Fatal dysrhythmias

2, Cardiac tamponade 3. Tension pneumothorax 5. Superior vena cava syndrome (Obstructive shock develops when a physical obstruction to blood flow occurs resulting in decreased cardiac output. This can be caused by restricted diastolic filling of the right ventricle from compression caused by cardiac tamponade, tension pneumothorax, or superior vena cava syndrome. Hypersensitivity to antibiotics may cause anaphylactic shock. Spinal cord injury may lead to neurogenic shock)

A patient is admitted to the hospital with a suspected diagnosis of obstructive shock. What could be the possible causes of this type of shock? Select all that apply. 1. Spinal cord injury 2. Cardiac tamponade 3. Tension pneumothorax 4. Hypersensitivity to antibiotics 5. Superior vena cava syndrome

1 2 3 6

A patient who suffered multiple fractures from a vehicle accident is being observed for potential development of multiple organ dysfunction syndrome (MODS). Which assessment data would indicate potential development of the syndrome? Select all that apply. 1 Severe dyspnea 2 Respiratory rate of 32 breaths/minute 3 Heart rate of 110 beats/minute 4 Urine Na+ of 18 mEq/L 5 BUN/creatinine ratio of 18:1 6 Blood pressure of 86/42 mm Hg

B (Symptoms of decompensated shock include slowing heart rate, systolic blood pressure less than 60 mm Hg, decreasing temperature, decreasing respiration rate, and almost no urine output as compensation mechanisms have failed and death is imminent. A. C. D. These manifestations do not indicate that the patient is in mild, moderate, or compensated shock.)

As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms should indicate to the nurse that the patient is in which stage of shock? A. Mildb. B. Severe C. Moderated. D. Compensated

4 (Rationale 1: Norepinephrine is not given to change cardiac enzymes. Rationale 2: The apical pulse would increase related to the catecholamine effects; therefore, reduced heart rate is not the intended outcome. Rationale 3: Norepinephrine is not given to reduce bleeding and may have the opposite effect. Rationale 4: Norepinephrine is a vasopressor used in shock to raise blood pressure.)

CARDIOGENIC TREATMENT A patient in shock is receiving norepinephrine by continuous infusion. For which outcome would the nurse monitor to evaluate the effectiveness of this medication? 1. Cardiac enzymes 2. Reduced apical heart rate 3. Reduction in bleeding 4. Blood pressure

B (Once the bleeding has stopped, a compression dressing and bulky bandage are applied and left in place to prevent disturbing clots gently. Elevating and immobilizing the injured part will help to control bleedinG)

HYPOVOLEMIC 17. The nurse has arrived on the scene of an accident. The victim is conscious and has a large bleeding laceration on his thigh. After the nurse uses an available towel to provide compression to the wound, what action should be performed next? a. The nurse should turn the patient to his left side. b. The nurse should elevate the patients affected leg. c. The nurse should bend the affected leg at the knee. d. The nurse should encourage the patient to perform leg pump exercises. g

C (ANS: C Given the acute nature of the patients blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patients blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.)

HYPOVOLEMIC SHOCK 20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6 F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patients heart rate.

29. ANS: C Epinephrine 30. ANS: D Administration of vasoconstrictors 32. ANS: B Hypovolemic shock 33. ANS: A Administration of inodilators

MATCH the shock state with the treatment a. Cardiogenic shock b. Hypovolemic shock c. Anaphylactic shock d. Neurogenic shock e. Insulin shock 29. Administration of epinephrine 30. Administration of vasoconstrictors 32. Administration of fluids 33. Administration of inodilators

B (The priority is to assess the patient in shock quickly, starting with the Cs: airway, breathing, circulation, and disability. A. Covering with blankets can occur after the initial rapid assessment is completed. C. The patients medical history can be obtained at a later time. D. The patient can be reoriented at a later time.)

On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first? a. Cover patient with warm blankets. b. Perform a rapid head-to-toe assessment. c. Obtain patients medical history from family. d. Reorient the patient to person, place, and time.

4 (Rationale 1: The ICU is not deliberately chilled; this is not the reason the patients hands are cold. Rationale 2: Fever and chills would not result in cold hands. Rationale 3: This response does not answer the familys question. Rationale 4: Vasoconstriction results from catecholamine release, which is a compensatory mechanism in shock. The diversion of warm blood)

Question 5 stages of shock/ cardiogenic A patient has developed severe cardiogenic shock and is on a mechanical ventilator. The family asks why the patients hands feel so cold. What is the nurses best response? 1. We keep the intensive care unit cool to reduce patients metabolic rates. 2. The patient has developed a fever and chills. 3. This happens frequently to patients in shock states. 4. Blood vessels constrict in shock, which takes the blood away from hands and feet.

B

STAGES OF SHOCK A critically ill patient has developed shock. What nursing assessment result indicates a normal compensatory mechanism? A) Reduction of respiratory depth B) Increase in systemic vascular resistance (SVR) C) Decrease in circulating catecholamines D) Increased stimulation of baroreceptors

A (The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.)

Stages of Shock 13. While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system

4 (Rationale 1: Acute Pain is an important nursing diagnosis but does not have the highest priority. Rationale 2: Family coping will probably be compromised and the nurse should address this issue. However, this is not the priority diagnosis. Rationale 3: Disturbed Body Image is an important nursing diagnosis but is not the highest priority. Rationale 4: Immediately after a burn injury, fluid begins to shift from the intracellular and intravascular compartment into the interstitial space. This third-spacing of fluid, if left untreated, will lead to hypovolemia and burn shock, which is life threatening. Also, edema develops in unburned tissues and organs distant from the site of injury when the burn size exceeds 20% of total body surface area.)

The nurse is admitting a 50-year-old female who was involved in a car accident and whose only injuries were burns over 50% of her body. Identify the highest-priority nursing diagnosis for this patient. 1. Acute Pain 2. Coping: Family, Compromised 3. Disturbed Body Image 4. Deficient Fluid Volume

2 (Rationale 1: The most common etiology of septic shock is an overwhelming infection. Rationale 2: The papillary muscle holds the valves in place and may be damaged during MI, the most common reason for cardiogenic shock. Rationale 3: Anaphylactic shock develops from hypersensitivity reactions. Rationale 4: Neurogenic shock results from spinal cord injury or vasodilatation below the level of spinal anesthesia.)

The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock? 1. Septic 2. Cardiogenic 3. Anaphylactic 4. Neurogenic

Increased PT, increased D-dimer, and decreased platelets indicate involvement of the hematologic system. Normal PT is 11-16 sec; normal platelets are 150-400 x 103/ μL, and normal D-dimer is less than 250 ng/mL. These all indicate involvement of the hematologic system. Normal Hct is 39%-50% for males and 35%-47% for females, thus this result is within normal range. RBC values range from 3.8/4.3-5.1/5.7 x 106/μL (male/female) thus this result is within normal limits.

The nurse is evaluating lab results related to the hematologic system for a patient diagnosed with multiple organ dysfunction syndrome (MODS) following a traumatic injury. Which lab results indicate involvement of the hematologic system? Select all that apply. 1 Hct 42% 2 PT 18 sec 3RBCs 5.0 x 106/μL 4 D-Dimer 280 ng/mL 5 Platelets 125 x 103/μL

D (Human serum albumin Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors.)

The nurse is mentoring a graduate nurse and is explaining the use of fluids in a patient who is experiencing hypovolemic shock. Which of the following fluids increases osmotic pressure to provide rapid volume expansion? A. Lactated Ringer's B. 3% sodium chloride C. Fresh frozen plasma D. Human serum albumin

124 (Dopamine is a positive inotropic agent used in cardiogenic shock. The drug may cause tissue sloughing, if infiltrated. Therefore it is administered through a central line and not via a peripheral line. The patient should be monitored for tachydysrhythmias caused by enhanced inotropic effects. There is also a risk of peripheral vasoconstriction, so the nurse should be observant for symptoms such as paresthesia and coldness of the extremities. The drug may get deactivated by an alkaline solution; therefore it should not be administered along with sodium bicarbonate. Because dopamine is not known to have an adrenergic action, it will not cause dyspnea and pulmonary edema.)

The nurse is taking care of a patient with cardiogenic shock due to a myocardial infarction. The health care provider prescribes dopamine to be administered. What nursing intervention should the nurse perform for administering dopamine? Select all that apply. 1 Administer via a central line. 2 Monitor for tachydysrhythmias. 3 Administer with sodium bicarbonate. 4 Monitor for peripheral vasoconstriction. 5 Monitor for dyspnea and pulmonary edema.

134 (Rationale 1: Obstruction of the vena cava can slow blood flow into the heart, resulting in obstructive shock. Rationale 2: This patient is at risk for hypovolemic shock from volume loss. Rationale 3: This injury could result in cardiac tamponade, which would lead to obstructive shock. Rationale 4: Rib fragments might damage the lung, causing a tension pneumothorax and possibly obstructive shock. Rationale 5: This patient is at risk of septic shock than obstructive shock)

The nurse would be most alert for assessment findings of obstructive shock in which patients? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. A patient who has tumor mass in the vena cava 2. A patient who sustained a gunshot wound to the abdomen 3. A patient who suffered a severe cardiac contusion 4. The patient who sustained several fractured ribs in a fall 5. A patient who has pneumonia caused by a multiple-drug-resistant organism

D

The patient is in decompensated cardiogenic shock. What collaborative intervention best addresses the central cause of cardiogenic shock? A) Mechanical ventilation B) Hemodynamic monitoring C) Pharmacologic sedation D) Intravenous nitrate infusion

d (to restore circulatory volume is the primary purpose)

What would the nurse identify as the primary purpose for the administration of intravenous (IV) crystalloid fluids in the patient with hypovolemic shock? A) Decrease myocardial oxygen demand. B) Maximize oxygen-carrying capability. C) Increase capillary permeability. D) Restore circulating volume.

3 4 5 (Correct Answer: 3,4,5 Rationale 1: A patient treated for lupus typically takes immunosuppressing drugs such as corticosteroids, which place the patient at risk for septic shock. Rationale 2: A myocardial infarction may lead to cardiogenic, not hypovolemic, shock. Rationale 3: Patients at risk for hypovolemic shock include those with hemorrhage, GI bleeding, third spacing, and unreplaced fluid loss. Ascites and anasarca are examples of third spacing. Rationale 4: Patients at risk for hypovolemic shock include those with chest and abdominal trauma. Rationale 5: Patients at risk for hypovolemic shock include those with hemorrhage and GI bleeding.)

Which patients would the nurse identify as being at increased risk for the development of hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. A patient with systemic lupus erythematosus 2. A patient who had a myocardial infarction 3. A patient with cirrhosis, ascites, and anasarca 4. A patient who was the unrestrained front-seat passenger in a multivehicle car crash 5. Patient with ruptured abdominal aortic aneurysm

123 (Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted.)

cardiogenic shock When examining a patient with cardiogenic shock, which signs of peripheral hypoperfusion does the nurse expect? Select all that apply. 1 Cyanosis 2 Cold skin 3 Weak pulse 4 Bradycardia 5 Hypertension Cyanosis, cold skin, and a weak pulse are the signs of peripheral hypoperfusion in cardiogenic shock. Bradycardia and hypertension are not seen in cardiogenic shock; instead, tachycardia and low blood pressure are noted.

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

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

2 4 5 (The patient may have increased glucose levels, increased sodium levels, and decreased potassium levels in the early stages of shock. Glucose levels increase due to the release of liver glycogen stores in response to sympathetic nervous system stimulation and cortisol. Sodium levels increase due to the increased secretion of aldosterone, causing renal retention of sodium. Potassium levels decrease because of the increased secretion of aldosterone, causing the renal excretion of potassium. Metabolic acidosis is a manifestation of late shock; respiratory alkalosis is seen in early shock due to hyperventilation. Increased liver enzymes indicate liver cell destruction in the progressive stage of shock.)

stages (early stage)A nurse has received the laboratory work of a patient who is suspected to have hypovolemic shock. What would be the laboratory findings if the patient is in the early stages of hypovolemic shock? Select all that apply. 1 Metabolic acidosis 2 Increased sodium levels 3 Increased liver enzymes 4 Increased glucose levels 5 Decreased potassium levels

B (When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. A. C. D. These findings are all within normal limits and do not necessarily indicate manifestations of early shock.

stages of shock A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6F (37C). Which finding should the nurse consider as a possible sign of early shock? a. Respirations 18/min b. Heart rate 118 beats/min c. Temperature 98.6F (37C) d. Blood pressure 130/90 mm Hg