Ch 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

c) Circulatory (distributive) Pg. 290 Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such condition as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

1. 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? a) Carcinogenic b) Hypovolemic c) Circulatory (distributive) d) Obstructive

b) Modified Trendelburg Pg. 285 The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.

11. 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? a) Trendelenburg b) Modified Trendelenburg c) Supine d) Semi-fowler's

b) Albumin Pg. 282 Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

14. Which colloid is expensive but rapidly expands plasma volume? a) Lactated Ringer solution b) Albumin c) Dextran d) Hypertonic saline

a) The difference between the systolic and diastolic pressure Pg. 277 The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

60. The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following? a) The difference between the systolic and diastolic pressure b) The difference between an apical and radial pulse c) The difference between an upper extremity and lower extremity blood pressure d) The difference between the arterial and venous blood pressure

d) Distributive Pg.

30. The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock? a) Cardiotonic b) Restrictive c) Hypervolemic d) Distributive

c) Low Pg. 285 The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

22. The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? a) Unable to measure b) High c) Low d) Normal

c) Reduces preload Pg.

28. Morphine sulfate has which of the following effects on the body? a) Increases preload b) Increases afterload c) Reduces preload d) No effect on preload or afterload

c) Myocardial infarction Pg. 287 Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

8. 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) Arrhythmias b) Cardiomyopathies c) Myocardial infarction d) Valvular damage

d) Bradycardia Pg. 296 The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

56. Which of the following is a clinical characteristic of neurogenic shock? a) Tachycardia b) Cool skin c) Moist skin d) Bradycardia

b) WBC: 42,000/mm3 Pg. 292 Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

10. The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? a) Potassium: 4.8 mEq/L b) WBC: 42,000/mm3 c) ESR: 19 mm/hour d) Hemoglobin: 14.2 g/dL

c) A rapid, bounding pulse Pg. 292 A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

12. The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? a) A slow but steady pulse b) A weak and thready pulse c) A rapid, bounding pulse d) A slow and imperceptible pulse

d) 15 minutes Pg. 283 When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

13. When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) 45 minutes b) Hourly c) 30 minutes d) 15 minutes

a) Organ damage Pg. 274 When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.

24. A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? a) Organ damage b) Unsteady gait c) Weight loss d) Liver dysfunction

d) Myocardial infarction Pg.

35. Cardiogenic shock is most commonly seen in which patient population? a) Stroke b) Spinal cord injury c) Head injury d) Myocardial infarction

d) Morphine Pg. 288 If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption.

67. 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? a) Meperidine b) Hydromorphone c) Codeine d) Morphine

b) Progressive Pg.

37. Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? a) Compensatory b) Progressive c) Refractory d) Irreversible

a) Skin color b) Vital signs c) Urine output d) Peripheral pulses Pg. 280 Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. 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.

38. 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. a) Skin color b) Vital signs c) Urine output d) Peripheral pulses e) Nutrition f) Gait

c) Decreased blood pressure Pg.

39. What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? a) Reduced preload b) Increased cardiac output c) Decreased blood pressure d) Reduced afterload

a) Nitroprusside Pg. 285 A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.

47. In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart? a) Nitroprusside b) Methoxamine c) Dopamine d) Epinephrine

d) Compensatory stage Pg.

34. The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? a) Initial stage b) Progressive stage c) Irreversible stage d) Compensatory stage

c) Cold, clammy skin and tachycardia Pg. 274 In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.

25. The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: a) Crackles and shallow breathing b) A heart rate of 140 c) Cold, clammy skin and tachycardia d) A systolic blood pressure of 75 mm Hg

d) 24 Pg.

33. The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? a) Palpable b) Within normal limits c) Thready d) 24

b) Tachycardia Pg. 276-277 The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

65. When a client is in the compensatory stage of shock, which symptom occurs? a) Urine output of 45 cc/hour b) Tachycardia c) Respiratory acidosis d) Bradycardia

c) <180 mg/dL Pg. 280 Tight glycemic control (serum glucose of 80 to 100 mg/dL) is no longer recommended, as hypoglycemic events associated with regulating tight control in critically ill clients have been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose levels lower than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the critically ill client.

20. A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client? a) <200 mg/dL b) <60 mg/dL c) <180 mg/dL d) <80 mg/dL

c) Urinary output d) Vital signs e) Mental status Pg. 282 Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.

15. When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) a) Visual acuity b) Ability to perform range of motion exercises c) Urinary output d) Vital signs e) Mental status

a) The right foot is cooler than the left foot Pg. 289 When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery.

16. 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: a) The right foot is cooler than the left foot b) Bilateral pedal pulses are 1+ c) The balloon deflates prior to systole d) Vesicular breath sounds are audible in the lung periphery

a) Famotidine (Pepcid) d) Lansoprazole e) Nizatidine Pg. 284-285 Antacids, H2 blockers (Pepcid, Axid), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.

17. Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Famotidine (Pepcid) b) Desmopressin c) Furosemide d) Lansoprazole e) Nizatidine

c) "A pulmonary artery pressure provides information about pressure on the left side of the heart" Pg. 289 The most pertinent information to share with a new nurse is the information that the pulmonary artery pressure provides essential information about the effectiveness of left ventricle. The left ventricle is most pertinent to circulation. The other information is correct but not as pertinent.

18. The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation? a) "Pulmonary artery pressure and pulmonary capillary pressure is assessed by an inserted catheter" b) "Central venous pressure reflects the pressure in the right atrium or venae cavae" c) "A pulmonary artery pressure provides information about pressure on the left side of the heart" d) "The trend in central venous pressure is more helpful than isolated readings"

b) Oxygen at 2 L/min by nasal cannula Pg. 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.

19. 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: a) Dopamine (Intropin) intravenous solution b) Oxygen at 2 L/min by nasal cannula c) NS at 60 mL/hr via an intravenous line d) Morphine 2 mg intravenously

b) Elevate the legs higher than the heart Pg. 280 The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.

2. The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? a) Shake the client to arouse b) Elevate the legs higher than the heart c) Cover the client with a blanket d) Place a cool compress on head

b) Disseminated intravascular coagulation (DIC) Pg. 280 Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.

21. 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? a) Stevens-Johnson syndrome from the administration of antibiotics b) Disseminated intravascular coagulation (DIC) c) Stress ulcer d) Septicemia

a) Respiratory rate c) Urine output d) Bilirubin level e) Platelet count f) Blood pressure Pg.

23. A client with a critical illness has a temperature of 38.5°C (101.3°F). Which parameters will the nurse use to determine if the client is developing sepsis? Select all that apply. a) Respiratory rate b) Cardiac rhythm c) Urine output d) Bilirubin level e) Platelet count f) Blood pressure

c) Adrenergic drugs Pg.

26. 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? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs

c) Administers oxygen by nasal cannula at 2 liters per minute Pg. 288 The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

27. A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Re-assesses the vital signs b) Contacts the admitting physician c) Administers oxygen by nasal cannula at 2 liters per minute d) Calls the Rapid Response Team

a) Brain Pg. 276 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.

29. 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? a) Brain b) Liver c) Lungs d) Kidneys

a) Mean arterial pressure of 70 mm Hg Pg. 276-277 The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

36. The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? a) Mean arterial pressure of 70 mm Hg b) Central venous pressure of 6 mm Hg c) ScvO2 of 60% d) Urine output of 0.2 mL/kg/hr

c) 3 to 5.1 L Pg. 285 The normal intravascular volume is 4 to 6 L. A reduction of 15% to 25% represents a loss of a minimum of 600 mL (4L @ 15%) to a maximum of 1,500 mL (6L @ 25%). Therefore 4,000 to 6,000 mL minus 600 to 1,500 mL = 3 to 5.1 L.

3. Hypovolemic shock is characterized by decreased intravascular volume. The nurse understands that shock would occur if the intravascular volume decreased by 15% to 25%. Therefore, for a 70 kg adult, hypovolemic shock would occur with a minimum intravascular volume of: a) 3.5 to 5.5 L b) 3.75 to 5.5 L c) 3 to 5.1 L d) 3.8 to 5.8 L

a) Monitor for changes in vital signs b) Administer intravenous fluids e) Assess the client who is at risk for shock Pg. 277 Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.

31. What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. a) Monitor for changes in vital signs b) Administer intravenous fluids c) Administer vasoconstrictive medications to clients at risk for shock d) Administer prophylactic packed red blood cells to clients at risk for shock e) Assess the client who is at risk for shock

b) Decompensation (progressive) Pg. 280 The decompensation or progressive stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.

32. At what point in shock does metabolic acidosis occur? a) Irreversible b) Decompensation (progressive) c) Early d) Late

a) Encourage the family to touch and talk to the client Pg. 281 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.

4. 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 a) Encourage the family to touch and talk to the client b) Inform the family that everything is being done to assist with the client's survival c) Open up discussion among the family members about nursing home placement d) Contact a spiritual advisor to provide comfort to the family

c) Adventitious breath sounds Pg. 290 The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

40. A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits a) Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute b) A change in apical pulse rate from 102 to 88 beats/min c) Adventitious breath sounds d) Troponin levels less than 0.35 ng/mL

d) Progressive Pg. 279 In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.

41. 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? a) Initial b) Compensatory c) Irreversible d) Progressive

b) Administer norepinephrine as prescribed Pg. 291-293 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. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

42. 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? a) Begin a continuous IV infusion of insulin per protocol b) Administer norepinephrine as prescribed c) Initiate enteral feedings as prescribed d) Administer recombinant human activated protein C (rhAPC) as prescribed

d) Progressive Pg. 276 In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

43. When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? a) Refractory b) Irreversible c) Compensatory d) Progressive

a) Kidney failure d) Disseminated intravascular coagulation e) Acute respiratory distress syndrome Pg.

44. A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. a) Kidney failure b) GERD c) Hypoglycemia d) Disseminated intravascular coagulation e) Acute respiratory distress syndrome

a) Compensatory respiratory alkalosis Pg. 276 In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The Pa CO2 would be increased in compensatory stage of shock. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid.

45. A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? a) Compensatory respiratory alkalosis b) PaCO2 >45 mm Hg c) Heart rate <100 bpm d) Metabolic acidosis

c) Circulatory (distributive) Pg. 290 Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock.

46. 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? a) Hypovolemic b) Cardiogenic c) Circulatory (distributive) d) Obstructive

d) Restores blood pressure Pg. 275 The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.

48. The nurse is caring for a client in the compensation stage of shock. One of the body's mechanisms of compensation in this stage of shock is the action of the renin-angiotensin-aldosterone system. What does this system do? a) Increases catecholamine secretion b) Increases the production of antidiuretic hormone c) Decreases peripheral blood flow d) Restores blood pressure

c) Neurogenic Pg. 296 The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.

49. Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? a) Anaphylactic b) Septic c) Neurogenic d) Cardiogenic

c) Organ damage Pg. 274 When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.

5. A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? a) Liver dysfunction b) Unsteady gait c) Organ damage d) Weight loss

a) A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume Pg.

50. A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? a) A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume b) A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces c) Generally caused by decreased blood volume d) Due to severe hypersensitivity reaction resulting in massive systemic vasodilation

b) Compensatory Pg. 277 The client's mentation, vital signs, and skin condition are those of a client in the compensatory stage of shock. Data are insufficient to support shock as either cardiogenic or circulatory in origin.

51. A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as a) Cardiogenic b) Compensatory c) Circulatory d) Progressive

c) Sodium nitroprusside Pg. 283 Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.

52. 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 a) Furosemide b) Dopamine c) Sodium nitroprusside d) Norepinephrine

c) Neurogenic Pg.

53. Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? a) Septic b) Cardiogenic c) Neurogenic d) Anaphylactic

d) 2.7 mL/hr Pg. 287 The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration).

54. The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? a) 11 mL/hr b) 8.0 mL/hr c) 5.5 mL/hr d) 2.7 mL/hr

b) Dextran Pg. 286 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.

55. 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 a) Plasma b) Dextran c) Salt-poor albumin d) Packed red blood cells

c) Antacids d) H2 blockers e) Proton pump inhibitors Pg. 284 Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, H2 blockers [e.g., famotidine (Pepcid)], and proton pump inhibitors [e.g., lansoprazole (Prevacid), esomeprazole magnesium (Nexium)] are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite.

57. A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. a) Promotility agents b) Proteases c) Antacids d) H2 blockers e) Proton pump inhibitors

c) Blood pressure falls Pg. 287 When stroke volume and heart rate decrease or become erratic, blood pressure falls, and systemic tissue perfusion is compromised (urine output decreases, cold, clammy skin, mental status changes, anxiety, and delayed capillary refill).

58. Which of the following clinical manifestations occur in cardiogenic shock? a) Skin is dry b) Urine output increases c) Blood pressure falls d) Quick capillary refill

a) Neurogenic Pg. 296 Neurogenic shock can be caused by spinal cord injury, spinal anesthesia, or other nervous system damage; client symptoms include dry skin and bradycardia with hypotension. Cardiogenic shock is seen in clients with impaired heart function. Hypovolemic shock is caused by decreased intravascular volume. Anaphylactic shock is caused by a severe allergic reaction; clients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction; specifically, an immunoglobulin E-mediated response.

59. 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? a) Neurogenic b) Anaphylactic c) Hypovolemic d) Cardiogenic

c) Sodium and glucose levels Pg. 277 In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.

6. The nurse is monitoring a patient in the compensatory stage of shock. What lab values does the nurse understand will elevate in response to the release of aldosterone and catecholamines? a) T3 and T4 b) BUN and creatinine c) Sodium and glucose levels d) Myoglobin and CK-MB

d) 70% Pg. 278 Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

61. 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? a) 40% b) 50% c) 60% d) 70%

c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing Pg. 284 The Centers for Disease Control and Prevention do not recommend hanging tape on bedside tables, siderails, linens, or clothing to use for dressings. The other options are activities that are proper infection control practices.

62. A nurse is assisting with the orientation of a newly hired graduate. Which of the following behaviors of the graduate nurse would the other nurse identify as not adhering to strict infection control practices? a) Rubbing the hands together with antiseptic solution until dry when exiting the client's room b) Swabbing the port of a central line for 15 seconds with an alcohol pad prior to medication administration c) Hanging tape on the bedside table when changing a wet-to-dry sterile dressing d) Wearing clean gloves when inserting a needle in preparation of starting intravenous fluids

c) An older adult man with end-stage renal disease and an infected dialysis access site Pg. 297 MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.

63. A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is a) A middle-aged woman with metastatic breast cancer and a BMI of 26 b) A young female adolescent who developed shock from tampon use during menses c) An older adult man with end-stage renal disease and an infected dialysis access site d) An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection

b) 60 mm Hg Pg. 275 Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.

64. The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. a) 80 mm Hg b) 60 mm Hg c) 90 mm Hg d) 70 mm Hg

a) Jugular venous distention Pg. 287 When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

66. 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) Positive increase in the fluid balance ratio c) Decreased pulse rate to 110 beats/minute d) Vesicular breath sounds

a) Dehydration c) Burns Pg. 285 The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

68. The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. a) Dehydration b) Trauma c) Burns d) Vomiting e) Diarrhea

d) Blood pressure Pg. 277 By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

69. Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: a) Heart rate b) Renal output c) Breath sounds d) Blood pressure

c) Modified Trendelenburg Pg. 285 A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

7. Which positioning strategy should be used for a client diagnosed with hypovolemic shock? a) Supine b) Prone c) Modified Trendelenburg d) Semi-Fowler

d) "The client is in shock because the blood volume has decreased in the system" Pg. 273 Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.

70. The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct? a) "The client is in shock because all peripheral blood vessels have massively dilated" b) "The client is in shock because your loved one is not responding and brain dead" c) "The client is in shock because the heart is unable to circulate the body fluids" d) "The client is in shock because the blood volume has decreased in the system"

b) Cardiogenic shock; myocardial infarction d) Septic shock; infection e) Hypovolemic shock; blood loss f) Anaphylactic shock; nut allergy Pg. 273 Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

71. A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. a) Neurogenic shock; diabetes b) Cardiogenic shock; myocardial infarction c) Obstructive shock; kidney stone d) Septic shock; infection e) Hypovolemic shock; blood loss f) Anaphylactic shock; nut allergy

d) 8 to 12 mm Hg Pg. 282 The goal in colloidal fluid replacement is to achieve a central venous pressure of 8 to 12 mm Hg or higher (normal = 2 to 8 mm Hg).

72. The nurse is administering colloids to a client during the first 6 hours of septic shock. What is the client's central venous pressure reading goal? a) 4 to 5 mm Hg b) 6 to 7 mm Hg c) 1 to 3 mm Hg d) 8 to 12 mm Hg

b) Septic Pg. 292 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. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.

73. 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) Septic c) Anaphylactic d) Cardiogenic

c) Constrict blood vessels in the cardiorespiratory system Pg. 283 Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

74. A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: a) Vasodilate the skeletal muscles b) Relax the bronchioles c) Constrict blood vessels in the cardiorespiratory system d) Decrease heart rate

a) Multiple organ failure Pg. 281 In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.

75. The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death? a) Multiple organ failure b) Limited gas exchange c) Endotoxins in the system d) Brain death

a) In the compensation stage, catecholamines are released Pg. 276 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.

76. You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? a) In the compensation stage, catecholamines are released b) The renin-angiotensin-aldosterone system fails in the compensation stage c) Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage d) Shock begins in the decompensation stage

a) Ondansetron Pg. 286 An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

77. A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next? a) Ondansetron b) Magnesium hydroxide c) Meperidine d) Loperamide

a) Aorta Pg. 275 Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall.

78. 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? a) Aorta b) Brachial artery c) Right ventricular wall d) Radial artery

d) Decompensation stage Pg. 280 Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly the dropping BP, indicate the decompensation stage. During the compensation stage of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During the irreversible stage, the client no longer responds to medical interventions, and multiple systems begin to fail. Cardiogenic shock is a type of shock.

79. A client at the scene of an MVA seems somewhat anxious and has clammy skin. The client's BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? a) Cardiogenic shock b) Compensation stage c) Irreversible stage d) Decompensation stage

a) Monitor temperature d) Administer oxygen therapy e) Obtain the lactate level Pg. 102 The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.

80. A nurse is assessing a client who is experiencing significant stress due to septicemia. The nurse should... Select all that apply. a) Monitor temperature b) Increase oral (PO) fluid intake c) Maintain prone position d) Administer oxygen therapy e) Obtain the lactate level

d) Increase in arterial oxygenation Pg. 276 Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. Catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.

81. The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? a) Regulation of sodium and potassium b) Decreased depressive symptoms c) Decreased white blood cell count d) Increase in arterial oxygenation

d) Bronchioles relax Pg. 283 When beta-2 adrenergic receptors are stimulated, vasodilation occurs in the heart and skeletal muscles, and the bronchioles relax.

82. When beta-2 adrenergic receptors are stimulated which of the following occur? a) Vasoconstriction in skeletal muscles b) Vasoconstriction in heart c) Bronchioles constrict d) Bronchioles relax

c) Lung sounds Pg. 282 The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

83. 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 a) Bowel sounds b) Mental status c) Lung sounds d) Skin perfusion

d) Aortic insufficiency Pg. 289 A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

9. 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? a) Diabetes mellitus b) Unstable angina pectoris c) Hypertension d) Aortic insufficiency