Shock PrepU

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.

60 mmHg

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?

Neurogenic

A 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?

Neurogenic shock

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.

Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Septic shock; infection

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

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply.

The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55-year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling

The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?

The difference between the systolic and diastolic pressure

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.

Vital signs Skin color Urine output Peripheral pulses

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 rapid, bounding pulse

A nurse is assessing a client who is experiencing significant stress due to septicemia. The nurse should ____, ____, and ____.

Administer oxygen therapy Obtain the lactate level Monitor temperature

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

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage?

Albumin

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?

Aortic insufficiency

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.

A nurse is caring for a client in cardiogenic shock. Which vasopressor agents may be used in the treatment of the client? Select all that apply.

Norepinephrine Epinephrine Vasopressin Phenylephrine

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?

Morphine

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

Narrowed pulse pressure

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?

Organ damage

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

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?

Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock.

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding.

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

Urinary output Mental status 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.

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?

WBC: 42,000/mm3

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 myocardial infarction.

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?

"The client is in shock because the blood volume has decreased in the system."

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

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

A continuous infusion of total parenteral nutrition

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.

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

Which of the following is the most common side effect of recombinant human activated protein C (rhAPC)?

Bleeding

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:

Blood pressure

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 who experienced shock remains unstable. Enteral nutritional supplements have been prescribed to prevent muscle wasting. The nurse

Consults with the physician about substituting lansoprazole (Prevacid) for the prescribed dose of pantoprazole (Protonix)

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?

Disseminated intravascular coagulation (DIC)

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.

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

Lung sounds

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Maintain activity restriction to bedrest.

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?

Modified Trendelenburg

Morphine sulfate has which of the following effects on the body?

Reduces preload

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?

Septic

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

Tachycardia