CH. 66: Shock, Sepsis and MODS

Which criterion is a clinical manifestation of sepsis? Infection Hypoglycemia Normal body temperature Systolic BP of 100 mm Hg or higher

Infection One clinical manifestation of sepsis is infection. Hypoglycemia, normal body temperature, and a systolic BP of 100 mm Hg or higher are not associated with sepsis. Rather, the nurse would expect hyperglycemia, fever, and hypotension as clinical manifestations of sepsis.

The nurse assesses a patient and suspects a diagnosis of neurogenic shock based on which findings? Select all that apply. Dyspnea Bradycardia Weak pulses Hypotension Unstable temperature

Signs of neurogenic shock include bradycardia, hypotension, and temperature instability. Dyspnea and weak pulses are not signs associated with neurogenic shock.

Which type of shock is associated with hyperglycemia, the presence of pulmonary infiltrates in a chest x-ray, and increased levels of blood urea nitrogen (BUN)? Septic Obstructive Cardiogenic Hypovolemic

Cardiogenic Increased blood levels of glucose, nitrogen, and cardiac markers, and the presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock.

The nurse anticipates which clinical findings in a patient who presents with anaphylactic shock? Select all that apply. Stridor Pruritus Anxiety Pallor Chest pain

Clinical findings associated with anaphylactic shock include stridor, pruritus, anxiety, and chest pain. The patient will experience skin flushing, not pallor.

Which goal for fluid resuscitation would the nurse choose when caring for a patient diagnosed with sepsis? Restore tissue perfusion. Increase circulating fluid volume. Restore blood flow to the myocardium. Maintain a mean arterial pressure of 50 mm Hg.

Restore tissue perfusion The goal for fluid resuscitation is the restoration of tissue perfusion. Increasing circulating fluid volume is the goal for hypovolemic shock. Restoring blood flow to the myocardium is the goal for cardiogenic shock. Maintaining a mean arterial pressure of 65 mm Hg is the goal when using vasopressors.

The nurse assesses a patient with cardiogenic shock and expects which findings? Select all that apply. Anxiety Tachycardia Hypertension Decreased urine output Weak peripheral pulses

The early presentation of a patient with cardiogenic shock is similar to that of a patient with acute decompensated heart failure (HF). The patient may have tachycardia. Signs of peripheral hypoperfusion (e.g., cyanosis, pallor, diaphoresis, weak peripheral pulses, cool and clammy skin, delayed capillary refill) occur. Decreased renal blood flow results in sodium and water retention and decreased urine output. Anxiety, confusion, and agitation may develop with impaired cerebral perfusion. The patient may have hypotension, not hypertension.

Which elements are included in the assessment of the tissue perfusion of a patient experiencing shock? Select all that apply. Vital signs Urine output Lung sounds Peripheral pulses Skin temperature Level of consciousness Assessing tissue perfusion includes evaluating vital signs, level of consciousness, peripheral pulses, capillary refill, skin (e.g., temperature, color, moisture), and urine output. Assessment of the patient's lung sounds is not part of the assessment of tissue perfusion.

Vital signs Urine output Peripheral pulses Skin temperature Level of consciousness Assessing tissue perfusion includes evaluating vital signs, level of consciousness, peripheral pulses, capillary refill, skin (e.g., temperature, color, moisture), and urine output. Assessment of the patient's lung sounds is not part of the assessment of tissue perfusion.

Which occurrence causes gut bacteria to move into circulation in patients with systemic inflammatory response syndrome (SIRS)? Toxic effects of medicines Effect of inflammatory mediators Decreased gastrointestinal (GI) motility Decreased perfusion of gut mucosa

Decreased perfusion of gut mucosa Decreased perfusion in the GI tract leads to a breakdown of the normally protective mucosal barrier, which causes the bacterial movement from the GI tract into circulation. To control these bacteria, antibiotics are administered. Antibiotics are nephrotoxic medicines that can cause acute kidney injury. The breakdown of the mucosal barrier is the direct effect of hypoperfusion rather than the inflammatory mediators. In critical illnesses, GI motility is often decreased, causing abdominal distention and paralytic ileus.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which physiologic change is associated with absolute hypovolemia? Third spacing Decreased afterload Absent cardiac output Decreased venous return

Decreased venous return A decrease in venous return is a physiologic change associated with absolute hypovolemia. Third spacing occurs in relative hypovolemia. The preload, not afterload, and cardiac output are decreased.

To which areas would the nurse attach a pulse oximetry probe to monitor the oxygen saturation on a patient in cardiogenic shock? Select all that apply. Ear Toes Nose Fingers Forehead

Ear, nose and forehead Pulse oximetry is used to monitor oxygen saturation. The patient in a state of shock has poor peripheral circulation, and a peripheral reading may not be accurate. Therefore the probe should be attached to the ear, nose, or forehead for a reliable measurement. Pulse oximetry readings obtained through the toes and fingers may not be accurate due to compromised peripheral circulation.

Which fluid increases osmotic pressure to provide rapid volume expansion for a patient experiencing hypovolemic shock? Lactated Ringer's 3% sodium chloride Fresh frozen plasma Human serum albumin

Human serum albumin is a colloidal fluid that increases osmotic pressure and will provide rapid volume expansion. Lactated Ringer's and 3% sodium chloride are used for initial volume replacement in shock, but they do not provide rapid volume expansion. Fresh frozen plasma is used to replace blood loss and replace coagulation factors.

Which type of shock can be treated by minimizing spinal cord trauma with stabilization? Septic shock Neurogenic shock Anaphylactic shock Hypovolemic shock

Neurogenic Neurogenic shock is caused by severe injury to the spinal cord and results in loss of sympathetic stimulation of blood vessels. Apart from administering vasoconstrictor agents, minimizing the spinal cord trauma with stabilization is a supporting therapy for neurogenic shock. Septic shock occurs in response to a systemic infection. Obtaining the cultures before starting antibiotics is appropriate care for septic shock. A life-threatening allergic reaction to a sensitizing substance causes anaphylactic shock. Avoiding exposure to allergens is supportive therapy for anaphylactic shock. Excessive loss of intravascular fluid causes hypovolemic shock. Besides restoring fluid volume, correcting the cause of fluid loss is supportive therapy.

Vasopressor agents are prescribed for which types of shock? Select all that apply. Septic Neurogenic Obstructive Cardiogenic Hypovolemic

Neurogenic and Septic Septic shock occurs in response to an infection. It is associated with the release of cytokines and other inflammatory mediators, resulting in vasodilatation, increased capillary permeability, and platelet aggregation. Vasopressors will constrict the blood vessels and relieve hypotension. Neurogenic shock is caused by a severe injury to the central nervous system (CNS), causing a loss of sympathetic stimulation of blood vessels resulting in vasodilatation. A fall in BP can be restored by administering vasopressor agents that act by constricting the blood vessels. Obstructive shock is caused by an obstruction in the vessels of the heart or the heart itself. Restoring the circulation by treating the cause of obstruction will be beneficial for a patient with obstructive shock. Systolic or diastolic dysfunction of the heart results in cardiogenic shock. Treatment involves use of nitrates, inotropes, diuretics, and β-blockers. A loss in the intravascular fluid volume causes hypovolemic shock. Treatment of hypovolemic shock includes restoring the fluid volume by infusion of blood or blood products and crystalloids.Test-Taking Tip: Identify option components as correct or incorrect. This may help you to identify a wrong answer.

Which nutritional component is most important for a patient with multiple organ dysfunction syndrome (MODS)? Protein Vitamins Minerals Carbohydrates

Protein Protein and calorie malnutrition is one of the primary signs of hypermetabolism in MODS. The goal of nutritional support is to preserve organ function by providing early and optimal nutrition. Vitamins, minerals, and carbohydrates may be incorporated into the patient's nutrition plan but are not as helpful as protein and calories.

A patient with an unobstructed airway experiences anaphylactic shock. Which initial action does the nurse take? Administer oxygen. Initiate fluid resuscitation. Prepare to intubate the patient. Initiate pharmacologic intervention.

Administer oxygen General management strategies for a patient experiencing anaphylactic shock include ensuring that the patient has a patent airway and is responsive. Once this has been established, oxygen delivery must be optimized to maintain an arterial saturation of 90% or greater. Fluid resuscitation is the foundation of therapy for a patient with anaphylactic shock; however, administering oxygen is the priority. A patient with an unobstructed airway does not require intubation. Pharmacologic intervention will be initiated to improve tissue perfusion.

Which pulmonary manifestation can be caused by systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)? Edema Fibrosis Embolism Hypertension

Hypertension SIRS and MODS affect the respiratory system and lead to pulmonary hypertension. Pulmonary edema is caused by fluid accumulation in the air spaces. Pulmonary fibrosis is a respiratory disorder caused by scars in the lung tissues or inhalation of airborne toxins. A pulmonary embolism is caused by blood clots or blockage in the pulmonary arteries.

Which manifestations are considered late signs of septic shock? Select all that apply. Cool skin Mottled skin Respiratory alkalosis Altered mental status Myocardial dysfunction

Cool skin Mottled skin Myocardial dysfunction Late signs of septic shock are cool and mottled skin and myocardial dysfunction. The release of platelet-activating factors increases coagulation, resulting in the formation of microthrombi and decreased blood flow in the microcirculation. The patient in early stages of septic shock may have warm and flushed skin, respiratory alkalosis, altered mental status, and decreased urine output.

Which types of shock are associated with decreased cerebral perfusion? Select all that apply. Septic shock Neurogenic shock Obstructive shock Cardiogenic shock Anaphylactic shock Hypovolemic shock

Decreased cerebral perfusion associated with obstructive shock causes anxiety, confusion, and agitation. Manifestations of cardiogenic shock include decreased cerebral perfusion that causes anxiety, confusion, and agitation. Decreased cerebral perfusion associated with hypovolemic shock causes anxiety, confusion, and agitation. Septic shock causes mental changes like confusion, agitation, and coma in the late stages. Loss of reflex activity and flaccid paralysis are seen with neurogenic shock. Anxiety, feeling of impending doom, confusion, decreased level of consciousness, and metallic taste are signs of anaphylactic shock.Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which nursing interventions would the nurse perform when administering dopamine to a patient experiencing cardiogenic shock? Select all that apply. Correct1 Administer via a central line. Correct2 Monitor for tachydysrhythmias. 3 Administer with sodium bicarbonate. Correct4 Monitor for peripheral vasoconstriction. 5 Monitor for pulmonary edema.

Dopamine is a positive inotropic agent used in cardiogenic shock. The drug may cause tissue sloughing, if infiltrated. Therefore it is administered through a central line and not via a peripheral line. The patient should be monitored for tachydysrhythmias caused by enhanced inotropic effects. There is also a risk for peripheral vasoconstriction, so the nurse should be observant for symptoms such as paresthesia and coldness of the extremities. The drug may get deactivated by an alkaline solution; therefore it should not be administered along with sodium bicarbonate. Because dopamine is not known to have an adrenergic action, it will not cause pulmonary edema.

3.Which type of shock is associated with bradycardia? Septic Neurogenic Anaphylactic Hypovolemic

Neurogenic shock is associated with bradycardia. Myocardial dysfunction and changes in body temperature are signs of septic shock. Chest pain is seen in anaphylactic shock. Reduction in preload, capillary refill, and stroke volume are clinical manifestations of hypovolemic shock.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which process occurs when the inflammatory response is activated in a patient with systemic inflammatory response syndrome (SIRS)? 1 Release of mediators 2 Decrease in metabolism 3 Damage of the mesothelium 4 Decrease in vascular permeability

Release of mediators

Which arterial blood gas finding is associated with a patient experiencing early shock? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory alkalosis is associated with early signs of shock as a result of hyperventilation. Metabolic acidosis and alkalosis, or respiratory acidosis, are not arterial blood gas findings related to early shock.

Which drug causes arterial and venous dilation? Dopamine Vasopressin Phenylephrine Sodium nitroprusside

Sodium nitroprusside Sodium nitroprusside acts by dilating both the arteries and veins. It is used in the treatment of cardiogenic shock. Dopamine has inotropic activity. It increases the force of the heartbeat and is used in the treatment of cardiogenic shock. Vasopressin is a vasoconstrictor used mainly in the treatment of septic shock. Phenylephrine acts by constricting the peripheral nerves and is used in the treatment of neurogenic shock.

The nurse expects which assessment findings in a patient with peritonitis who is experiencing early septic shock? Select all that apply. Correct1 Crackles 2 Coma Correct3 Decreased urine output Incorrect4 Cool and mottled skin Correct5 A heart rate of 120 beats/min

The clinical presentation of a patient with early septic shock includes crackles, decreased urine output, and tachycardia. Coma and cool and mottled skin occur with late septic shock.

A patient is newly admitted to an intensive care unit (ICU) with septic shock. The nurse anticipates which type of enteral nutritional therapy? The calories will be adjusted based on daily weights. The patient will be started on a small amount of nutrition (10 mL/hr). The patient will be started on feedings after the condition stabilizes. The total albumin is used to determine the patient's nutritional status.

The patient will be started on a small amount of nutrition (10 mL/hr). Patients are started on a trophic feeding, which is a small amount of enteral nutrition. Daily weights are a better indicator of fluid status than caloric needs due to the third spacing of fluids. Eternal nutrition should be started within the first 24 hours due to the hypermetabolic state of the patient. Serum protein, total albumin, prealbumin, blood urea nitrogen (BUN), serum glucose, and serum electrolytes are all used to assess nutritional status.

The nurse provides care for a patient with neurogenic shock whose spine has been stabilized. The nurse prioritizes treatment of the patient's hypotension and bradycardia for which primary purpose? To restore circulating volume To prevent oxygen loss to the brain To restore the oxygen delivery to the heart To prevent further spinal cord damage

To prevent further spinal cord damage The primary purpose of restoring the hypotension and bradycardia of a patient experiencing neurogenic shock is to prevent further spinal cord damage. Restoring circulatory volume is a goal for the patient with hypovolemic and septic shock. The primary treatment of hypotension and bradycardia for a patient with spinal cord damage is not to prevent oxygen loss to the brain. Restoring oxygen delivery to the heart is a goal for a patient with cardiogenic shock.

Which type of shock causes an absence of bowel sounds? Neurogenic Cardiogenic Hypovolemic Anaphylactic

Hypovolemic Absence of bowel sounds is associated with hypovolemic shock. Decreased bowel sounds are seen with cardiogenic shock. Bowel dysfunction is associated with neurogenic shock. Abdominal pain, nausea, and vomiting are seen with anaphylactic shock.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

Which nursing diagnosis would be the priority for a patient with hypovolemic shock? Acute pain Impaired tissue integrity Decreased cardiac output Ineffective tissue perfusion

Ineffective tissue perfusion The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output because circulation is a priority. Acute pain may occur but is not a priority at this time. Tissue integrity is not impaired.

The nurse provides care for a patient experiencing shock. Assessment findings are indicative of decreasing cardiac output and decreased peripheral perfusion. The nurse identifies that the patient is in which stage of shock? 1 Initial 2 Refractory 3 Progressive 4 Compensatory

Progressive The cardiovascular system is profoundly affected in the progressive stage of shock. Manifestations of the progressive stage of shock include decreased cardiac output, which leads to decreased BP and increased heart rate (HR). Other manifestations include decreased peripheral perfusion, which leads to ischemia of distal extremities, decreased pulses, and decreased capillary refill. The initial stage of shock is usually not accompanied by clinical changes. During the refractory stage, decreasing coronary blood flow continues to occur, which leads to worsening myocardial depression. During the compensatory phase, coronary arterial dilation occurs, resulting in improved blood flow to the heart.