Ch. 14: Shock and Mods PrepU
When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) 30 minutes b) 15 minutes c) 45 minutes d) Hourly
15 minutes Correct Explanation: When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).
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) Thready b) Palpable c) Within normal limits d) 24
24 Correct Explanation: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A continuous infusion of total parenteral nutrition b) An infusion of crystalloids at an increased rate of flow c) A full liquid diet d) Isotonic enteral nutrition every 6 hours
A continuous infusion of total parenteral nutrition Correct Explanation: Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.
A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? a) Generally caused by decreased blood volume. b) A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. c) A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces. d) Due to severe hypersensitivity reaction resulting in massive systemic vasodilation.
A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Correct Explanation: Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependant edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock.
You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? a) A slow but steady pulse b) A slow and imperceptible pulse c) A rapid, bounding pulse d) A weak and thready pulse
A rapid, bounding pulse Correct Explanation: 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.
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) A change in apical pulse rate from 102 to 88 beats/min b) Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute c) Adventitious breath sounds d) Troponin levels less than 0.35 ng/mL
Adventitious breath sounds Correct Explanation: 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.
Which of the following is a clinical characteristic of neurogenic shock? a) Bradycardia b) Tachycardia c) Cool skin d) Moist skin
Bradycardia Correct Explanation: 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.
A 74-year-old male client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock? a) Distributive shock b) Hypovolemic shock c) Obstructive shock d) Cardiogenic shock
Cardiogenic shock Correct Explanation: Cardiogenic shock is caused by decreased force of ventricular contraction. Both myocardial infarction and cardiac dysrhythmia may cause cardiogenic shock. This type of shock is characterized by an impaired filling of heart with blood due to mechanical impediment, such as cardiac tamponade, dissecting aneurysm, or tension pneumothorax. This type of shock is caused by the enlargement of the vascular compartment and redistribution of intravascular fluid from arterial circulation to venous or capillary areas. Hypovolemic shock is caused by decreased blood volume with decreased filling of the circulatory system. Typical examples are hemorrhage, extreme dieresis, and third-spacing.
A 28-year-old female client at the scene of an MVA seems somewhat anxious; her skin is clammy and her BP has dropped to 90 mm Hg. What stage of shock is this client most likely experiencing? a) Cardiogenic shock b) Irreversible stage c) Compensation stage d) Decompensation stage
Decompensation stage Explanation: Although shock can develop quickly, early signs and symptoms are evident during the decompensation stage. This client's symptoms, particularly her dropping BP, indicate she is in the decompensation stage. During this first phase of shock, physiologic mechanisms attempt to stabilize the spiraling consequences. During this stage, the client no longer responds to medical interventions. Multiple systems begin to fail. This term refers to a type of shock.
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) Dextran b) Hetastarch c) Salt-poor albumin d) Packed red blood cells
Dextran Correct Explanation: 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.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance? a) Elevate the legs higher than the heart. b) Place a cool compress on head. c) Cover the client with a blanket. d) Shake the client to arouse.
Elevate the legs higher than the heart. Correct Explanation: 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.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance? a) Place a cool compress on head. b) Cover the client with a blanket. c) Elevate the legs higher than the heart. d) Shake the client to arouse.
Elevate the legs higher than the heart. Correct Explanation: 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.
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Head injury b) Multiple sclerosis c) Diabetes d) Myocardial infarction
Head injury Correct Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.
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) Increase in arterial oxygenation c) Decreased white blood cell count d) Decreased depressive symptoms
Increase in arterial oxygenation Correct Explanation: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of 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.
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? a) Dilate the bronchial tree b) Increase the force of myocardial contraction c) Slow the heart rate d) Depress the central nervous system
Increase the force of myocardial contraction Correct Explanation: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: a) Jugular venous distention b) Vesicular breath sounds c) Positive increase in the fluid balance ratio d) Decreased pulse rate to 110 beats/minute
Jugular venous distention Correct Explanation: 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.
A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first a) Maintains the head of the bed at 30 degrees b) Administers a bolus of intravenous (IV) fluids c) Assesses the client's blood glucose level d) Lays the client flat with the feet elevated
Lays the client flat with the feet elevated Explanation: The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated.
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) Skin perfusion b) Bowel sounds c) Lung sounds d) Mental status
Lung sounds Correct Explanation: 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.
Which positioning strategy should be used for the patient diagnosed with hypovolemic shock? a) Modified Trendelenburg b) Semi-Fowler's c) Supine d) Prone
Modified Trendelenburg Correct Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.
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) Brain death b) Limited gas exchange c) Endotoxins in the system d) Multiple organ failure
Multiple organ failure Correct Explanation: 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.
A 17-year-old-male client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? a) Septic shock b) Neurogenic shock c) Anaphylactic shock d) Hypovolemic shock
Neurogenic shock Explanation: Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma.
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) NS at 60 mL/hr via an intravenous line b) Oxygen at 2 L/min by nasal cannula c) Morphine 2 mg intravenously d) Dopamine (Intropin) intravenous solution
Oxygen at 2 L/min by nasal cannula Correct Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.
The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation? a) Pedal pulse stronger b) Temperature within normal limits c) Respiratory rate decreased d) Heart rate increased
Pedal pulse stronger Correct Explanation: The ventricular assist device (VAD) is a medical mechanical device used to improve cardiac output and redistribute blood. The best evidence to confirm successful implementation is by identifying a strong pedal pulse in a lower extremity. Respiratory rate decreases as a client rests. Heart rate decreases when the tissues obtain the needed oxygen. The temperature within normal limits does not confirm successful implementation.
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) Septic b) Neurogenic c) Cardiogenic d) Anaphylactic
Septic Correct Explanation: 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.
The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Anaphylactic b) Cardiogenic c) Neurogenic d) Septic
Septic Correct Explanation: Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with disease of the heart. Anaphylactic shock is associated with hypersensitivity reactions.
Which following types of shock is caused by an infection? a) Septic b) Hypovolemic c) Anaphylactic d) Cardiogenic
Septic Correct Explanation: Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when intravascular volume is decreased. Anaphylactic shock is caused by a hypersensitivity reaction.
You are assessing a 6-year-old little girl in the emergency department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child? a) She is having an allergic reaction and going into anaphylactic shock. b) She is having an allergic reaction and going into obstructive shock. c) She is having an allergic reaction and going into cardiogenic shock. d) She is having an allergic reaction and going into neurogenic shock.
She is having an allergic reaction and going into anaphylactic shock. Correct Explanation: Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive (see Ch. 34). Common allergic substances include bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract to release histamine and other chemicals. The results are vasodilatation, increased capillary permeability accompanied by swelling of the airway and subcutaneous tissues, hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and obstructive shock would not begin with vasodilation, swelling of the airway, and hives. Therefore, options A, C,and D are incorrect.
When a patient is in the compensatory stage of shock, which of the following symptoms occurs? a) Urine output of 45 mL/hr b) Bradycardia c) Tachycardia d) Respiratory acidosis
Tachycardia Correct Explanation: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? a) The difference between an upper extremity and lower extremity blood pressure b) The difference between the systolic and diastolic pressure c) The difference between the arterial and venous blood pressure d) The difference between an apical and radial pulse
The difference between the systolic and diastolic pressure Correct Explanation: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. a) Cardiogenic shock; myocardial infarction b) Neurogenic shock; diabetes c) Obstructive shock; kidney stone d) Anaphylactic shock; nuts e) Septic shock; infection f) Hypovolemic shock; blood loss
• Cardiogenic shock; myocardial infarction • Anaphylactic shock; nuts • Septic shock; infection • Hypovolemic shock; blood loss Correct Explanation: 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.
A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. a) Neurogenic shock; diabetes b) Septic shock; infection c) Anaphylactic shock; nuts d) Hypovolemic shock; blood loss e) Obstructive shock; kidney stone f) Cardiogenic shock; myocardial infarction
• Septic shock; infection • Anaphylactic shock; nuts • Hypovolemic shock; blood loss • Cardiogenic shock; myocardial infarction Correct Explanation: 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.
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) Nutrition b) Urine output c) Skin color d) Gait e) Peripheral pulses f) Vital signs
• Vital signs • Skin color • Urine output • Peripheral pulses Explanation: 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.
The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. Appropriate interventions include (Select all that apply) a) monitoring urine output every hour b) administering pantoprazole (Protonix) IV daily c) obtaining a urine specimen for culture d) maintaining the IV site inserted on admission e) instituting vital signs every 4 hours
• obtaining a urine specimen for culture • administering pantoprazole (Protonix) IV daily • monitoring urine output every hour Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole, would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours.