Complex Ch 14: Shock
When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal? a) Preserve the healthy myocardium b) Limit further myocardial damage c) Treat the oxygenation needs of the heart muscle d) Improve the heart's pumping mechanism
Answer: (page )
In which type of shock does the patient experience a mismatch of blood flow to the cells? a) Septic b) Distributive c) Cardiogenic d) Hypovolemic
Answer: (page )
When the nurse observes that the patient's systolic blood pressure is less than 80 to 90 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc per hour, the nurse recognizes that the patient is demonstrating which stage of shock? a) Irreversible b) Refractory c) Progressive d) Compensatory
Answer: (page )
Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order. 1 Assess the capillary blood glucose level. 2 Place the client in the modified Trendelenburg position. 3 Initiate an intravenous (IV) site and prescribed IV fluids. 4 Collect a stool specimen for culture.
Answer: (page )
Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis? a) Progressive b) Precompensatory c) Compensatory d) Irreversible
Answer: D The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, rapid, shallow respirations. There is not a stage of shock called the precompensatory stage. (page 292)
A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? a) Notify a physician. b) Call 911. c) Obtain the name and information of the allergic substance. d) Administer an epinephrine injection.
Answer: D The key words in the question are "increasing symptoms."The first action of the nurse is to administer an epinephrine injection to abort the rapidly increasing symptoms. Next, the nurse will call 911. (page 306)
How should vasoactive medications be administered? a) By rapid intravenous (IV) push b) Intramuscularly (IM) c) Using a central venous line d) Through a peripheral IV line
Answer: C Vasoactive medications should be administered through a central venous line, because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV push (page294 )
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? a) Progressive b) Initial c) Compensatory d) Irreversible
Answer: A In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline (page290 )
In the treatment of shock, which of the following vasoactive drugs results in reduced preload and afterload, reducing the oxygen demand of the heart? a) Nitroprusside (Nipride) b) Epinephrine (Adrenaline) c) Methoxamine (Vasoxyl) d) Dopamine (Intropin)
Answer: A A disadvantage of nitroprusside is that it causes hypotension. Dopamine improves contractility, increases stroke volume, and increases cardiac output. Epinephrine improves contractility, increases stroke volume, and increases cardiac output. Methoxamine increases blood pressure by vasoconstriction (page 296)
Which of the following colloids is expensive but rapidly expands plasma volume? a) Albumin b) Hypertonic saline c) Dextran d) Lactated Ringer's
Answer: A Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer's and hypertonic saline are crystalloids, not colloids. (page 304)
A client has the following vital signs: temperature 101.4 degrees F, blood pressure 88/54, pulse 128 beats/minute, and respirations 34 breaths/minute. Physician orders are shown in the accompanying chart. The nurse first intervenes by a) Increasing DRLR to the prescribed rate b) Providing acetaminophen for the elevated temperature c) Obtaining the blood cultures d) Administering the Vancomycin
Answer: A All these options are appropriate for the client who is in septic shock, but the nurse would first administer the IV fluids to restore vascular volume. Blood cultures would be obtained prior to administration of any antibiotics. Acetaminophen is given to provide comfort to the client. (page 304)
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? a) Aorta b) Radial artery c) Right ventricular wall d) Brachial artery
Answer: A Arterial baroreceptors are located in the carotid sinus and aorta. There aren't any baroreceptors in the brachial artery, radial artery, or right ventricular wall. (page 286)
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? a) Intubation and mechanical ventilation b) Administration of oxygen via venture mask c) Pericardiocentesis d) Thoracotomy with chest tube insertion
Answer: A Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate. (page 290)
Morphine sulfate has which of the following effects on the body? a) Reduces preload b) No effect on preload or afterload c) Increases preload d) Increases afterload
Answer: A In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). (page 299)
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? a) "The client is in shock because the blood volume has decreased in the system." b) "The client is in shock because all peripheral blood vessels have massively dilated." c) "The client is in shock because the heart is unable to circulate the body fluids." d) "The client is in shock because your loved one is not responding and brain dead."
Answer: A Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents. (page 285)
A nurse assesses a client who is in cardiogenic shock. What statement best indicates the nurse's understanding of cardiogenic shock? a) A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. b) A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces. c) Generally caused by decreased blood volume. d) Due to severe hypersensitivity reaction resulting in massive systemic vasodilation.
Answer: A Shock may have different causes (e.g., hypovolemic, cardiogenic, septic) but always involves a decrease in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Option B could reflect dependant edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock
Vasoactive drugs, which cause the arteries and veins to dilate thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as which of the following? a) Sodium nitroprusside (Nipride) b) Furosemide (Lasix) c) Dopamine (Intropin) d) Norepinephrine (Levophed)
Answer: A Sodium nitroprusside is used in the treatment of cardiogenic shock. Norepinephrine (Levophed) is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine (Intropin) tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide (Lasix) is a loop diuretic that reduces intravascular fluid volume. (page 296)
The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? a) Low b) High c) Normal d) Unable to measure
Answer: A The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure. (page 295)
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Administers oxygen by nasal cannula at 2 liters per minute b) Contacts the admitting physician c) Re-assesses the vital signs d) Calls the Rapid Response Team
Answer: A The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen. (page 288)
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? a) Modified Trendelenburg b) Semi-Fowler's c) Supine d) Trendelenburg
Answer: A The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output. (page 297)
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 a) Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family.
Answer: A The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option. (page 292)
A client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse a) Raises the foot of the client's bed b) Elevates the head of the client's bed c) Turns the client to a side-lying position d) Places the client in a Trendelenburg position
Answer: A The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return. (page 297)
You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock? a) Distributive b) Hypervolemic c) Restrictive d) Cardiotonic
Answer: A The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect. (page 300)
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) A slow but steady pulse b) A rapid, bounding pulse c) A weak and thready pulse d) A slow and imperceptible pulse
Answer: B A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular. (page 301)
A patient is admitted to the emergency department (ED) following a motorcycle accident. Upon assessment, the patient's vital signs reveal blood pressure (BP) of 80/60 mm Hg and heart rate (HR) of 145 beats per minute (bpm). The patient's skin is cool and clammy. Which of the following patient medical orders will the nurse complete first? a) 100% oxygen per nonrebreather mask b) C-spine x-rays c) Two large-bore IVs and begin crystalloid fluids d) Type and cross match
Answer: A The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address the metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied per a nonrebreather mask. The other orders should be completed after the patient's airway is secured. (page 292)
The nurse is caring for a patient newly diagnosed with sepsis. The patient has a serum lactate level of 6 mmol/L and fluid resuscitation has been initiated. Which of the following indicates that the fluid resuscitation received by the patient is adequate? a) Mean arterial pressure (MAP) of 70 mm Hg b) ScvO2 of 60% c) Central venous pressure (CVP) of 6 mm Hg d) Urine output of 0.2 mL/kg/hr
Answer: A The nurse administers fluids to achieve a target CVP of 8 to 12 mm Hg, MAP > 65 mm Hg, urine output > 0.5 mL/kg/hr, and an ScvO2 > 70%. (page 303)
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? a) The difference between the systolic and diastolic pressure b) The difference between an apical and radial pulse c) The difference between the arterial and venous blood pressure d) The difference between an upper extremity and lower extremity blood pressure
Answer: A The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure. (page 288)
A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as a) Progressive b) Neurogenic c) Hypovolemic d) Compensatory
Answer: A The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin. (page 290)
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? a) Circulatory (distributive) b) Obstructive c) Carcinogenic d) Hypovolemic
Answer: A Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcatagories. (page 286)
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? a) Circulatory (distributive) b) Cardiogenic c) Obstructive d) Hypovolemic
Answer: A Vasodilatation, a prominent characteristic of circulatory/distributive shock, increases the space in the vascular bed. Central blood flow is reduced because peripheral vascular or interstitial areas exceed their usual capacity. Vasodilation is not a major component of cardiogenic, hypovolemic, or obstructive shock. (page 300)
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. a) Vital signs b) Urine output c) Skin color d) Gait e) Peripheral pulses f) Nutrition
Answer: A, B, C, E Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised.Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation. (page 288)
What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the patient's prognosis? (Select all that apply.) a) Monitor for changes in vital signs. b) Assess the patient who is at risk for shock. c) Administer prophylactic packed red blood cells to patients at risk for shock. d) Administer intravenous fluids. e) Administer vasoconstrictive medications to patients at risk for shock.
Answer: A, B, D Early intervention along the continuum of shock is the key to improving the patient's prognosis (Jones, Brown, Trzeciak, et al., 2008). The nurse must systematically assess the patient at risk for shock, recognizing subtle clinical signs of the compensatory stage before the patient's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention. (page 288)
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.<<< a) Urine output b) Gait c) Nutrition d) Skin color e) Vital signs f) Peripheral pulses
Answer: A, D, E, F Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised.Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation. (page 288)
You are caring for a client with a stage IV leg ulcer. You are closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that you should notify the physician of immediately? a) The client exhibits an increased urinary output. b) The client's heart rate is greater than 90 beats per minute. c) The client's respiratory rate is less than 20 breaths per minute. d) The client feels restless and hungry.
Answer: B A heart rate greater than 90 beats per minute or a respiratory rate greater than 20 breaths per minute will indicate that sepsis has occurred. Sepsis does not increase the client's appetite or affect the client's urinary output. (page 302)
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 mediciations would the nurse administer next? a) magnesium hydroxide (Maalox) b) ondansetron (Zofran) c) loperamide (Imodium) d) meperidine (Demerol)
Answer: B An antiemetic medication, such as ondansetron, is administered for vomiting. It would be administered before loperamide for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine) or heartburn (magnesium hydroxide). (page 297)
A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? a) "Administer oxygen by nasal cannula at 3 L/minute." b) "Infuse I.V. fluids at 83 ml/hour." c) "Monitor urine output every hour." d) "Draw samples for hemoglobin and hematocrit every 6 hours."
Answer: B Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client. (page 296)
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? a) Decreased depressive symptoms b) Increase in arterial oxygenation c) Regulation of sodium and potassium d) Decreased white blood cell count
Answer: B Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium. (page285 )
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? a) Antiduretic and corticosteroid hormones are released at the beginning of the irreversible stage. b) In the compensation stage, catecholamines are released. c) Shock begins in the decompensation stage. d) The renin-angiotensin-aldosterone system fails in the compensation stage.
Answer: B 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. Shock does not begin in the decompensation stage. (page 287)
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? a) 50% b) 70% c) 60% d) 40%
Answer: B Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70% (Ramos & Azevedo, 2010). (page 289)
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) A continuous infusion of total parenteral nutrition c) Isotonic enteral nutrition every 6 hours d) An infusion of crystalloids at an increased rate of flow
Answer: B Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition. (page 304)
Which of the following type of shock are older adults more likely to develop? a) Septic shock b) Cardiogenic shock c) Neurogenic shock d) Anaphylactic shock
Answer: B Older adults, particularly those with cardiac disease, are prone to cardiogenic shock. Older adults are not prone to developing neurogenic, septic, or anaphylactic shock. (page 299)
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? a) Arrange personal care supplies nearby. b) Maintain activity restriction to bedrest. c) Avoid heavy meals. d) Limit interaction with visitors.
Answer: B Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity. (page 298)
Which following types of shock is caused by an infection? a) Anaphylactic b) Septic c) Hypovolemic d) Cardiogenic
Answer: B Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when intravascular volume is decreased. Anaphylactic shock is caused by a hypersensitivity reaction (page 301)
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 a) A change in apical pulse rate from 102 to 88 beats/min b) Adventitious breath sounds c) Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute d) Troponin levels less than 0.35 ng/mL
Answer: B The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction. (page 300)
You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body? a) Release of catecholamines b) Production of antidiuretic hormone and corticosteroid hormones c) Activation of renin-angiotensin-aldosterone system d) Secretion of epinephrine and norepinephrine
Answer: B Thus, they play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones, then, promote fluid re absorption and retention. The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. The release of catecholamines stimulates secretion of epinephrine and norepinephrine. (page 287, 294)
The nurse is calculating a patient's mean arterial pressure (MAP). What is the patient's MAP, if the blood pressure is 110/70 mm Hg? a) 91 b) 83 c) 65 d) 73
Answer: B Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. MAP must exceed 65 mm Hg for cells to receive the oxygen and nutrients needed to metabolize energy in amounts sufficient to sustain life (Dellinger et al., 2013; Tuggle, 2010). True MAP can be calculated only by complex methods. An estimate of MAP may be calculated by using the following equation: MAP = DP + 1/3 (SP - DP). So, in this case, MAP = 70 + 1/3 (110-70) = 70 + 40/3 = 70 + 13.33 = 83.33, which rounds to 83. (page 286)
Which of the following is a vasodilator that is used in the treatment of shock? a) Dobutamine (Dobutrex) b) Nitroglycerin (Tridil) c) Dopamine (Intropin) d) Norepinephrine (Levophed)
Answer: B Tridil is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Intropin and Dobutrex are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Levophed is a vasoconstrictor used to increase blood pressure by vasoconstriction. (page 296)
The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? a) Blood products b) 5% albumin c) 6% dextran d) 6% hetastarch
Answer: B Typically, if colloids are used to treat tissue hypoperfusion, albumin is the agent prescribed. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated during production to reduce its potential to transmit disease. The disadvantage of albumin is its high cost compared to crystalloid solutions. Hetastarch and dextran solutions are not indicated for fluid administration because these agents interfere with platelet aggregation. Blood products are not indicated in this situation. (page 293)
When vasoactive medications are administered, the nurse must monitor vital signs at least how often? a) Hourly b) 15 minutes c) 30 minutes d) 45 minutes
Answer: B When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated). (page 294)
Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? >>>Select all that apply.<<< a) Desmopressin (DDAVP) b) Ranitidine (Zantac) c) Lansoprazole (Prevacid) d) Famotidine (Pepcid) e) Furosemide (Lasix)
Answer: B, C, D Antacids, H2 blockers (Pepcid, Zantac), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. DDVAP is used in the treatment of diabetes insipidus. Lasix is a loop diuretic and does not prevent ulcer formation. (page 295)
You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs
Answer: C Adrenergic drugs are the main medications used to treat shock. This makes options A, B, and D incorrect. (page 294)
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? a) Codeine b) Dilaudid c) Morphine d) Demerol
Answer: C If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption. (page 299)
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? a) Increase in systolic blood pressure b) Decrease in respiratory rate c) Narrowed pulse pressure d) Increase in diastolic pressure
Answer: C Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP (Strehlow, 2010). Decreased or narrowing pulse pressure is an early indication of decreased stroke volume. (page 288)
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? a) Cardiogenic b) Septic c) Neurogenic d) Anaphylactic
Answer: C The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds. (page 304)
When a patient is in the compensatory stage of shock, which of the following symptoms occurs? a) Urine output of 45 mL/hr b) Respiratory acidosis c) Tachycardia d) Bradycardia
Answer: C The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis. (page 288)
The nurse is evaluating a 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? a) Unsteady gait b) Liver dysfunction c) Organ damage d) Weight loss
Answer: C When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs which fail. Weight fluctuations may occur if the body holds fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client is not able to ambulate. (page 292)
A patient presents to the emergency department (ED) with her husband. The patient appears in respiratory distress. The husband states "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which of the following agents first? a) IV infusion of normal saline b) Albuterol (Proventil) nebulizer c) Diphenhydramine (Benadryl) IV d) Epinephrine (Adrenalin) intramuscularly (IM)
Answer: D All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive actions. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability. (page 306)
A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) treat hypertension. b) prevent sinus bradycardia. c) treat hypotension. d) increase cardiac output.
Answer: D Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure. (page 299)
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? a) Cardiogenic b) Neurogenic c) Anaphylactic d) Septic
Answer: D In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress. (page 302)
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? a) Irreversible b) Compensatory c) Refractory d) Progressive
Answer: D 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. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the patient does not respond to treatment and cannot survive. In the compensatory state, the patient's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart. (page 290)
A 17-year-old-male 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? a) Septic shock b) Anaphylactic shock c) Hypovolemic shock d) Neurogenic shock
Answer: D Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. Septic shock is a subcategory of distributive shock, but it is associated with overwhelming bacterial infections. Anaphylactic shock is a subcategory of distributive shock, but it is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive, such as bee venom, latex, fish, nuts, and penicillin. Hypovolemic shock is not a subcategory of distributive shock. It occurs when the volume of extracellular fluid is significantly diminished, primarily because of lost or reduced blood or plasma. (page 304)
Which of the following is a clinical characteristic of neurogenic shock? a) Cool skin b) Tachycardia c) Moist skin d) Bradycardia
Answer: D The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. (page 304)
A patient is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which of the following assessment findings indicate the patient may be experiencing neurogenic shock? a) Cool, moist skin b) HR: 120 bpm; BP 88/58 mm Hg c) Shortness of breath d) HR: 48 bpm; BP: 90/60 mm Hg
Answer: D The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock. (page304 )
Clinical characteristics of neurogenic shock are noted by which type of stimulation? a) Sympathetic b) Cerebral c) Endocrine d) Parasympathetic
Answer: D The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation. (page 305)
At what point in shock does metabolic acidosis occur? a) Compensation b) Irreversible c) Early d) Decompensation (Progressive)
Answer: D The decompensation or progressive stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis. Therefore, options A, B, and C are incorrect. (page288 )