Sr Med Surg: PrepU Ch 14: Shock & Multiple Organ Dysfunction Syndrome

Which type of shock occurs from an antigen-antibody response?

anaphylactic

Why is blood the most important measure of shock?

by the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels

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 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 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 70mmHg

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

tachycardia

The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the parent. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child?

the child is having an allergic reaction & going into anaphylactic shock

Why do stress ulcers occur frequently in acutely ill patients?

the compromised blood supply to the gastrointestinal tract

Which is an indicator of renal hypoperfusion?

urinary output of less than 30 mL/hr

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?

urine output, platelet count, bilirubin level, blood pressure, respiratory rate, mean arterial pressure, serum creatinine, and Glasgow Coma Scale score

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

Why is the patient in the progressive stage of shock at risk for GI bleeding?

GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock

A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock?

HR 48 bpm, BP 90/60 mmHg

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with?

Intubation and mechanical ventilation

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

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

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?

neurogenic shock

What are the symptoms of the compensatory stage of shock?

normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition?

300 mL

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?

8-12 mmHg

Which colloid is expensive but rapidly expands plasma volume?

albumin

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

albumin

A client has been treated for shock and is now at risk for which secondary but life-threatening complications?

kidney failure, disseminated intravascular coagulation (DIC), acute respiratory distress syndrome

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 knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.

60mmHg

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:

myocardial infarction

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?

70%

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

An older adult man with end-stage renal disease and an infected dialysis access site

Why is modified trendelenburg the recommended position for the patient with 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

What are the vasopressor agents that increase blood pressure by vasoconstriction?

Levophed, Intropin, Neo-Synephrine, and Pitressin

What is the major clinical use of dobutamine?

increase cardiac output

How does Lactated Ringer's help treat acidosis?

it's an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate

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

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

a continuous infusion of total parenteral nutrition

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 rapid, bounding pulse

Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation?

acid base imbalance, increased capillary permeability and fluid & electrolyte shifts, increased blood urea nitrogen & serum creatinine, MAP less than 65 mmHg

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?

administer epinephrine injection as ordered by HCP

A nurse is assessing a client who is experiencing significant stress due to septicemia. What interventions should the nurse provide?

administer oxygen therapy, monitor temperature, obtain lactate level

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?

adrenergic drugs

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

A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers?

antacids, H2 blockers, proton pump inhibitors

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 can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis?

assess the client who is at risk for shock, administer intravenous fluids, monitor for change in vital signs

The nurse is caring for a client who develops hypotension, declining mental status, and severely decreased urinary output. Which intravenous fluid will the nurse expect to be prescribed for this client?

lactated ringer's solution

What are the common allergic substances?

bee venom, latex, fish, nuts, and penicillin

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

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

levophed

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following?

low

A 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?

cardiogenic shock

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 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, tachycardia

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit?

compensatory respiratory alkalosis

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 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

At what point in shock does metabolic acidosis occur?

decompensation (progressive)

What does distributive shock result from?

displacement of blood volume

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 nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?

distributive

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

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?

distributive

What are the clinical characteristics of neurogenic shock?

dry, warm skin, bradycardia, hypotension

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?

elevate the legs higher than the heart

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?

ondansetron

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 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

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

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

reduces preload

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

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

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?

sodium and glucose levels

What are some things that can cause neurogenic shock?

spinal cord injury, spinal ansesthesia, or other nervous system damage

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 & diastolic pressure

What occurs in the progressive stage of shock?

the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits

What does continuous central venous oximetry (ScvO2) monitor?

used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states

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

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 & talk to the client

What does cardiogenic shock result from?

failure of heart to pump

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation?

famotidine (pepcid), nizatidine, lansoprazole

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?

hanging tape on the table when changing a wet-to-dry sterile dressing

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

head injury

What are the four main categories of shock?

hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause

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

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

modified trendelenburg

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

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?

vital signs, urine output, skin color, peripheral pulses

What occurs during disseminated intravascular coagulation (DIC)?

widespread clotting and bleeding occur simultaneously

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?

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