Chapter 14: Shock PrepU

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:

Cold, clammy skin and tachycardia.

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?

Distributive

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

Encourage the family to touch and talk to the client.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?

Myocardial depression

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?

In the compensation stage, catecholamines are released.

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?

Progressive

How should vasoactive medications be administered?

Using a central venous line

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

Adventitious breath sounds

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?

Aorta

What is the consequence of the release of catecholamines in the skeletal muscles during the compensation stage of shock?

Blood supply to the skeletal muscles increases.

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?

Circulatory (distributive)

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?

Compensatory stage

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.

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis?

Irreversible

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:

Oxygen at 2 L/min by nasal cannula

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

Progressive

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?

Progressive

When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?

Treat the o2 needs of the heart muscle

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 mediciations would the nurse administer next?

ondansetron

The nurse would observe an elevated leukocyte count and a fever accompanied by warm, flushed skin during the assessment of a client who has

an overwhelming bacterial infection.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)

Mental status Urinary output Vital signs

When a client is in the compensatory stage of shock, which symptom occurs?

Tachycardia

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?

24

The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate?

3:1

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin

Which pulse pressure indicates shock?

90/70 mm HG

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

A continuous infusion of total parenteral nutrition

A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock?

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

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.)

A heart rate >100 bpm Crackles Lethargy and mental confusion

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:

Constrict blood vessels in the cardiorespiratory system.

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

Dextran

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?

Increase in arterial oxygenation

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:

Jugular venous distention

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis?

Lactated Ringer's

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?

Mean arterial pressure of 70 mm Hg

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.

Monitor for changes in vital signs. Administer intravenous fluids. Assess the client who is at risk for shock.

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?

Multiple organ failure

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.

Skin color Peripheral pulses Urine output Vital signs

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?

Use strict hand hygiene techniques

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.

antacids H2 blockers proton pump inhibitors