AHIV Exam 2: Shock
A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client? A) Cardiogenic shock B) Hypovolemic shock C) Neurogenic shock D) Septic shock
Answer: A Explanation: A) Older adults who have a heart attack, especially those with a history of heart failure, diabetes, or hypertension, have an increased risk of cardiogenic shock. Therefore, the nurse should be monitoring the client for signs and symptoms of cardiogenic shock and be prepared to respond immediately to any warning signs of shock. Older adults are also at higher risk for progressing to other types of shock, but this client is at highest risk for cardiogenic shock.
A client is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply. A) Muscle spasms B) Tachycardia C) Confusion D) Gastrointestinal bleeding E) Disorientation
Answer: A, B, C, E Explanation: A) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply. A) Slight increase in pulse B) Dry, warm skin C) Increased urine output D) Normal respirations E) Slight decrease in blood pressure
Answer: A, D, E Explanation: A) Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations, and normal to slightly decreased blood pressure. Manifestations also include cool, moist skin and a slight decrease in urine output.
The nurse is caring for a child who was burned in a house fire. The child has burns on 30% of his body, particularly his legs. The child suddenly goes into shock and needs CPR. What is the first step the nurse should take based on pediatric advanced life support (PALS) guidelines? A) Begin ventilations B) Begin chest compressions C) Obtain a defibrillator D) Establish vascular access
Answer: B Explanation: A) Based on PALS guidelines, the first step in providing life support to a child is to immediately begin chest compressions. This is the first step because no equipment is needed, so compressions can begin immediately. A second healthcare provider should begin ventilations with a bag and mask. A monitor and defibrillator should be obtained as the third step. Establishing vascular access should be the fourth step. The final step is calculating and preparing anticipated medications based on the child's weight.
The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client? A) Auscultate breath sounds for inspiratory stridor B) Auscultate breath sounds for crackles C) Auscultate breath sounds for hyperresonance D) Auscultate for an absence of breath sounds in the lower lobes
Answer: B Explanation: A) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. Stridor is auscultated with airway obstruction, not pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
A client with hemophilia is at increased risk for what type of shock? A) Cardiogenic shock B) Hemorrhagic shock C) Anaphylactic shock D) Distributive shock
Answer: B Explanation: A) Because clients with hemophilia have a decreased ability to form clots, they are at high risk for hemorrhagic shock. They are not at higher risk for cardiogenic, anaphylactic, or distributive shock unless they also have other underlying conditions, such as advanced cardiac disease or severe allergies.
The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective? A) "It's a protein that causes my kidneys to conserve fluid." B) "It's a protein that pulls water into my blood vessels." C) "It's a liquid that has electrolytes in it to pull water into my blood vessels." D) "It's a super-concentrated salt solution that helps me conserve body fluid."
Answer: B Explanation: A) Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Albumin 5% does not act on the kidneys. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% is not a concentrated saline solution.
What is the purpose of using warm IV fluids to help resuscitate clients in shock? A) To increase vasodilation B) To prevent hypothermia C) To prevent hyperthermia D) To increase vasoconstriction
Answer: B Explanation: A) Using room-temperature fluids can cause hypothermia, which may hinder the effectiveness of treatment. Therefore, warmed IV fluids should be used to help resuscitate clients in shock. Use of warm IV fluids does not cause vasodilation or vasoconstriction, and it does not prevent hyperthermia.
A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. What does the nurse understand about the physiology of progressive shock? A) It involves a sustained decrease of 10 mmHg of the client's mean arterial pressure (MAP). B) It involves a blood loss of 25%. C) It involves a change from aerobic to anaerobic metabolism. D) It involves a decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
Answer: C Explanation: A) In decompensated or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35-50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate? A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."
Answer: C Explanation: A) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock. Liver failure, kidney failure, and respiratory failure are not types of shock.
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as: A) Class I B) Class II C) Class III D) Class IV
Answer: C Explanation: A) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-2,000mL, or 30-40% of blood volume.
A client who is taking beta-adrenergic blockers for angina is experiencing hypovolemic shock. Which does the nurse anticipate being the priority collaborative intervention for this client? A) Administering analgesics for control of pain B) Assessing the cause of bleeding C) Providing replacement of volume D) Establishing invasive cardiac monitoring
Answer: D Explanation: A) Clients who take beta blockers may not present with tachycardia as an early indicator of shock. These individuals will require early invasive monitoring to avoid excessive or inadequate volume restoration. Replacement of volume would occur after invasive cardiac monitoring is established. Pain would be a consideration but would not be attended to as a first priority. Assessing the cause of bleeding would also occur after establishing invasive cardiac monitoring.
What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin? A) Hypovolemic shock B) Cardiogenic shock C) Neurogenic shock D) Septic shock
Answer: D Explanation: A) Early septic shock is characterized by normal to slightly decreased blood pressure; increased pulse and respirations; warm, flushed skin; and chills, among other symptoms. In hypovolemic and cardiogenic shock, the skin will typically be pale and cool rather than warm and flushed. In neurogenic shock, the pulse will be slow and bounding rather than rapid.
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client? A) Deficient Fluid Volume B) Ineffective Coping C) Ineffective Airway Clearance D) Decreased Cardiac Output
Answer: D Explanation: A) The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping. There is not enough information to determine whether the client has ineffective airway clearance.