4510-EAQ Shock

Which change in the client's lab results indicates that the client is in septic shock? 1. Blood glucose of 80 mg/dL 2. An increased serum lactate level 3. An increased neutrophil level 4. A white blood count (WBC) of 5000 cells/µL

An increased serum lactate level Rationale: The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count >12,000 cells/µL or <4,000 cells/µL, and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 mg/dL and >150 mg/dL. Blood glucose levels of 70 mg/dL to 100 mg/dL are considered normal.

Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock? 1. Cold, clammy skin 2. Slow, bounding pulse 3. Increased blood pressure 4. Hyperactive bowel sounds

Cold, clammy skin Rationale: In cardiogenic shock, the action of the sympathetic nervous system causes vasoconstriction, which causes the skin to be cold and clammy. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs. Because of poor cardiac contractility, pulse quality is weak. Blood pressure decreases because of poor cardiac output. Hypoperfusion leads to hypoactive or absent bowel sounds.

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? 1. Slow heart rate 2. Cool skin temperature 3. Bounding radial pulses 4. Increased urine output

Cool skin temperature Rationale: Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion. Tachycardia, not bradycardia (slow heart rate), occurs as a compensatory mechanism in hypovolemic shock. The pulses in hypovolemic shock are weak and thready because of decreased blood pressure. Urine output will decrease because of decreased kidney perfusion in hypovolemic shock.

Which clinical findings would the nurse expect when assessing a client who has cardiogenic shock? Select all that apply. One, some, or all responses may be correct. 1. Pallor 2. Agitation 3. Tachycardia 4. Narrow pulse pressure 5. Decreased respirations

Pallor, Agitation, Tachycardia, Narrow pulse pressure Rationale: Pale skin (pallor), agitation, tachycardia, and narrow pulse pressure are signs of cardiogenic shock due to decreased cardiac output. Respiratory rate will increase with cardiogenic shock as a compensatory mechanism for poor tissue oxygenation.

Which nursing intervention would prevent septic shock in the hospitalized client? 1. Maintain the client in a normothermic state. 2. Administer blood products to replace fluid losses. 3. Use aseptic technique during all invasive procedures. 4. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures. Rationale: Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? Select all that apply. One, some, or all responses may be correct. 1. Spasticity 2. Incontinence 3. Flaccid paralysis 4. Respiratory failure 5. Lack of reflexes below the injury

Flaccid paralysis, Lack of reflexes below the injury Rationale: Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Transection of the spinal cord caused the spinal shock and resulted in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs because of decreased tone of the bladder and bowel; thus incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating the level of injury is below C4 and respirations are not affected.

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1. Urticaria 2. Tachycardia 3. Restlessness 4. Laryngeal edema

Laryngeal edema Rationale: Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.

The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect? 1. Hypokalemia 2. Metabolic acidosis 3. Respiratory alkalosis 4. Decreased carbon dioxide level

Metabolic acidosis Rationale: Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Metabolic acidosis Rationale: Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. As shock progresses, eventually respiratory acidosis can result from decreased respiratory function in late shock. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? 1. Implanted port 2. Midline catheter 3. 18-gauge peripheral venous catheter 4. Peripherally inserted central catheter (PICC) line

Peripherally inserted central catheter (PICC) line Rationale: Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. Implanted ports are also central lines, used mainly for chemotherapy, but require specialized needles and staff who are trained in accessing the port. Midline catheters are peripherally inserted in the antecubital area or upper arm and are not recommended for infusion of vesicants because large amounts of fluid may escape into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? 1. Decreased rate of glomerular filtration 2. Excessive blood loss through the burned tissues 3. Plasma proteins moving out of the intravascular compartment 4. Sodium retention occurring as a result of the aldosterone mechanism

Plasma proteins moving out of the intravascular compartment Rationale: The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

Which clinical manifestations would the nurse observe in a client experiencing a full-blown anaphylactic shock from a type I latex allergic reaction? Select all that apply. One, some, or all responses may be correct. 1. Stridor 2. Fissuring 3. Hypotension 4. Dyspnea 5. Cracking of the skin

Stridor, Hypotension, Dyspnea Rationale: Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.

Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct. 1. Tachycardia 2. Restlessness 3. Warm, moist skin 4. Decreased urinary output 5. Bradypnea

Tachycardia, Restlessness, Decreased urinary output Rationale: The heart rate increases (tachycardia) and the respiratory rate increases (tachypnea, not bradypnea) in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/h because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. One, some, or all responses may be correct. 1. Bradycardia 2. Hypotension 3. Spastic paralysis 4. Urinary retention 5. Increased pulse pressure

Bradycardia, Hypotension, Urinary retention Rationale: Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. Urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and has hypovolemic shock. Which site(s) would be used to obtain the client's pulse rate? Select all that apply. One, some, or all responses may be correct. 1. Apical 2. Carotid 3. Brachial 4. Femoral 5. Popliteal

Carotid, Femoral Rationale: Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. The popliteal site is used to assess the status of the circulation in the lower leg.

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? 1. Urine output 1000 mL in 8 hours 2. Oral temperature 101°F (38.3°C) 3. Client report of feeling very thirsty 4. Bounding radial and femoral pulses

Client report of feeling very thirsty Rationale: With hypovolemic shock, extravascular fluid depletion leads to client feeling of thirst. With hypovolemia, urine output will decrease due to compensatory mechanisms designed to retain volume. Elevated temperature might occur with septic shock, but temperature may be lower with hypovolemia because of poor perfusion. With hypovolemia, pulses would be weak.

Which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 beats/minute to 121 beats/minute? 1. Septic shock 2. Cardiogenic shock 3. Hemorrhagic shock 4. Neurogenic shock

Hemorrhagic shock Rationale: With a history of a traumatic injury and abdominal pain associated with assessment findings of hypotension and tachycardia, the most likely type of shock is hemorrhagic. A client with septic shock would have tachycardia and hypotension, but symptoms would also include fever and warm, flushed skin. Cardiogenic shock might also present with tachycardia and hypotension, but the client would report chest discomfort and dyspnea. Neurogenic shock presents with hypotension and bradycardia.

Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? 1. Obstructive 2. Neurogenic 3. Cardiogenic 4. Hypovolemic

Hypovolemic Rationale: Hypovolemic shock occurs because of blood loss from the circulation when an abdominal aneurysm ruptures. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from spinal cord or head injury, which cause vasodilation due to loss of sympathetic nervous system vasoconstrictor tone. Cardiogenic shock results from a decrease in cardiac output.

Which assessment finding presents the highest risk for cardiac shock? 1. Pulse 104 beats/minute 2. Respirations 22 breaths/minute 3. Temperature 98.9°F (37.2°C) 4. Blood pressure 114/68 mm Hg

Pulse 104 bpm Rationale: Any pulse higher than 100 beats/minute should be of great concern. A respiratory rate of 22 breaths/minute is within the normal range; a temperature of 98.9°F (37.2°C) or a blood pressure reading of 114/68 mm Hg is not a concerning assessment finding.

A client who sustained serious burns now has a stress ulcer. If complications occur, which clinical indicators of shock would the nurse immediately report to the primary health care provider? Select all that apply. One, some, or all responses may be correct. 1. Weakness 2. Diaphoresis 3. Tachycardia 4. Cold extremities 5. Flushed skin tone

Weakness, diaphoresis, tachycardia, cold extremities Rationale: The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed, because of peripheral vasoconstriction.