SG Chapter 66

When caring for a patient in cardiogenic shock, the nurse recognizes that the metabolic demands of turning and moving the patient exceed the oxygen supply when what change is revealed in hemodynamic monitoring? a. SvO2 from 62% to 54% b. CO from 4.2 L/min to 4.8 L/min c. Stroke volume (SV) from 52 to 68 mL/beat d. SVR from 1300 dyne/sec/cm5 to 1120 dyne/sec/cm5

a. SvO2 from 62% to 54%

Septic: Fluid resuscitation, antimicrobial agents, inotropic agents with vasopressors

Anaphylactic: Epinephrine, inhaled bronchodilators, colloidal fluid replacement, diphenhydramine, corticosteroids

Cardiogenic: Restore coronary artery blood flow with thrombolytic therapy, angioplasty, emergency revascularization; increase CO with inotropic agents; reduce workload by dilating coronary arteries, decreasing preload and afterload; use circulatory assist devices, such as an intraaortic balloon pump

Hypovolemic: Fluid and blood replacement, control of bleeding with pressure, surgery

The patient is admitted with an unusual infection. The nurse knows that a mechanical tissue trauma that can trigger SIRS will not occur with this patient because what types of injuries cause a mechanical tissue trauma trigger of SIRS (SATA)? a. Burns b. Fungi c. Viruses d. Crush injuries e. Surgical procedures

a. Burns d. Crush injuries e. Surgical procedures

What physical problems could precipitate hypovolemic shock (select all that apply)? a. Burns b. Ascites c. Vaccines d. Insect bites e. Hemorrhage f. Ruptured spleen

a. Burns b. Ascites e. Hemorrhage f. Ruptured spleen

What intervention may prevent GI bacterial and endotoxin translocation in a critically ill patient with SIRS? a. Early enteral feedings b. Surgical removal of necrotic tissue c. Aggressive multiple antibiotic therapy d. Strict aseptic technique in all procedures

a. Early enteral feedings

The patient is in the compensatory stage of shock. What manifestations indicate this to the nurse (select all that apply)? a. Pale and cool b. Unresponsive c. Lower BP than baseline d. Moist crackles in the lungs e. Hyperactive bowel sounds f. Tachypnea and tachycardia

a. Pale and cool c. Lower BP than baseline f. Tachypnea and tachycardia

A 70-year-old patient is malnourished, has a history of type 2 diabetes mellitus, and is admitted from the nursing home with pneumonia. For which kind of shock should the nurse closely monitor this patient? a. Septic shock b. Neurogenic shock c. Cardiogenic shock d. Anaphylactic shock

a. Septic shock

A patient with hypovolemic shock is receiving lactated Ringer's solution for fluid replacement therapy. During this therapy, which laboratory result is most important for the nurse to monitor? a. Serum pH b. Serum sodium c. Serum potassium d. Hemoglobin (Hgb) and hematocrit (Hct)

a. Serum pH

In the compensatory stage of hypovolemic shock, to what organs does blood flow decrease after the sympathetic nervous system activates the α-adrenergic stimulation (select all that apply)? a. Skin b. Brain c. Heart d. Kidneys e. Gastrointestinal tract

a. Skin d. Kidneys e. Gastrointestinal tract

Which indicators of tissue perfusion should be monitored in critically ill patients by the nurse (SATA)? a. skin b. Urine output c. LOC d. ADLs e. VS, including pulse ox f. Peripheral pulses with cap refill

a. skin b. Urine output c. LOC e. VS, including pulse ox f. Peripheral pulses with cap refill

A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, what is the most important for the nurse to assess? a. Urine output b. Breath sounds c. Peripheral circulation d. Central venous pressure

b. Breath sounds

The nurse determines that a large amount of crystalloid fluids administered to a patient in septic shock is effective when hemodynamic monitoring reveals what? a. CO of 2.6 L/min b. CVP of 15 mm Hg c. PAWP of 4 mm Hg d. Heart rate (HR) of 106 bpm

b. CVP of 15 mm Hg

Which patient manifestations confirm the development of MODS? a. Upper GI bleed, GCS score of 7, Hct: 25% b. Elevated serum bilirubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000/uL c. Urine output of 30 mL/hr, BUN of 45 mg/dL, and WBC of 1120/uL d. RR: 45, PaCO2: 60 mmHg, Chest x-ray with bilateral diffuse patchy infiltrates

b. Elevated serum bilirubin, serum creatinine of 3.8 mg/dL, and platelet count of 15,000/uL

Which hemodynamic monitoring description of the identified shock is accurate? a. Tachycardia with hypertension is characteristic of neurogenic shock. b. Increased pulmonary artery wedge pressure (PAWP) and a decreased cardiac output (CO) in cardiogenic shock c. Anaphylactic shock is characterized by increased systemic vascular resistance (SVR), decreased CO, and decreased PAWP. d. In septic shock, bacterial endotoxins cause vascular changes that result in increased SVR and decreased CO.

b. Increased pulmonary artery wedge pressure (PAWP) and a decreased cardiac output (CO) in cardiogenic shock

What abnormal finding should the nurse expect to find in early compensatory shock? a. Metabolic acidosis b. Increased serum sodium c. Decreased blood glucose d. Increased serum potassium

b. Increased serum sodium

A patient with severe trauma has been treated for hypovolemic shock. The nurse recognizes that the patient is in the irreversible stage of shock when what is included in assessment findings? a. A lactic acidosis with a pH of 7.32 b. Marked hypotension and refractory hypoxemia c. Unresponsiveness that responds only to painful stimuli d. Profound vasoconstriction with absent peripheral pulses

b. Marked hypotension and refractory hypoxemia

When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. Distributive shock b. Obstructive shock c. Cardiogenic shock d. Hypovolemic shock

b. Obstructive shock

The nurse suspects sepsis as a cause of shock when the laboratory test results indicate a. hypokalemia. b. thrombocytopenia. c. decreased hemoglobin. d. increased blood urea nitrogen (BUN)

b. thrombocytopenia.

Which interventions should be used for anaphylactic shock (SATA)? a. Antibiotics b. Vasodilators c. Antihistamines d. O2 supplementation e. Colloid volume expansion f. Crystalloid volume expansion

c. Antihistamines d. O2 supplementation e. Colloid volume expansion f. Crystalloid volume expansion

Priority Decision: What is the priority nursing responsibility in the prevention of shock? a. Frequently monitoring all patients' vital signs b. Using aseptic technique for all invasive procedures c. Being aware of the potential for shock in all patients at risk d. Teaching patients health promotion activities to prevent shock

c. Being aware of the potential for shock in all patients at risk

When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of the therapy? a. Increasing urine output to 50 mL/hr b. Constriction of vessels to maintain BP c. Maintaining a MAP of at least 60 mm Hg d. Dilating vessels to improve tissue perfusion

c. Maintaining a MAP of at least 60 mm Hg

A patient in the progressive stage of shock had rapid, deep respirations. The nurse determines that the patient's hyperventilation is compensating for metabolic acidosis when the patient;s arterial blood gas (ABG) results include: a. pH 7.42, PaO2 80 mmHg b, pH 7.44, PaO2 69 mmHg c. pH 7.38, PaCO2 30 mmHg d. pH 7.32, PaCO2 48 mmHg

c. pH 7.38, PaCO2 30 mmHg

Which statement describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate? a. MODS may occur independently from SIRS b. All patients with septic shock develop MODS c. The GI system is often the first to show evidence of dysfunction in SIRS and MODS d. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin

d. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin

Priority Decision: A patient with acute pancreatitis is experiencing hypovolemic shock. Which initial orders for the patient will the nurse implement first? a. Start 1000 mL of normal saline at 500 mL/hr. b. Obtain blood cultures before starting IV antibiotics. c. Draw blood for hematology and coagulation factors. d. Administer high-flow oxygen (100%) with a non-rebreather mask.

d. Administer high-flow oxygen (100%) with a non-rebreather mask.

As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs related to the increased angiotensin II? a. Vasodilation b. Decreased blood pressure (BP) and CO c. Aldosterone release results in sodium and water excretion d. Antidiuretic hormone (ADH) release increases water reabsorpton

d. Antidiuretic hormone (ADH) release increases water reabsorpton

Progressive tissue hypoxia leading to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contribute to this increasing tissue hypoxia? a. Arterial constriction causes decreased perfusion. b. Vasoconstriction decreases blood flow to pulmonary capillaries. c. Increased capillary permeability and profound vasoconstriction cause increased hydrostatic pressure. d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells.

d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and decreased oxygen delivery to cells.

During administration of IV norepinephrine (Levophed), what should the nurse assess the patient for? a. Hypotension b. Marked diuresis c. Metabolic alkalosis d. Decreased tissue perfusion

d. Decreased tissue perfusion

What is the key factor in describing any type of shock? a. Hypoxemia b. Hypotension c. Vascular collapse d. Inadequate tissue perfusion

d. Inadequate tissue perfusion

In late irreversible shock in a patient with massive thermal burns, what should the nurse expect the patient's laboratory results to reveal? a. Respiratory alkalosis b. Decreased potassium c. Increased blood glucose d. Increased ammonia (NH3) levels

d. Increased ammonia (NH3) levels

What mechanism that can trigger SIRS is related to MI or pancreatitis? a. Abscess formation b. Microbial invasion c. Global perfusion deficits d. Ischemic or necrotic tissue

d. Ischemic or necrotic tissue

A patient in shock has a nursing diagnosis of fear related to severity of condition and perceived threat of death as manifested by verbalization of anxiety about condition and fear of death. What is an appropriate nursing intervention for the patient? a, administer antianxiety agents b, allow caregivers to visit as much as possible c. call a member of the clergy to visit as much as possible d. inform the patient of the current plan of care and its rationale

d. inform the patient of the current plan of care and its rationale