Prep-U Chapter 14: Shock and Multiple Organ Dysfunction Syndrome

A 57-year-old client has been brought to your ED via squad. He is unresponsive, and his wife reports his symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. His labs show an elevated WBC; cultures are forthcoming. You suspect which of the following may be the cause of the client's present condition?

Septic

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

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?

The client's heart rate is greater than 90 beats per minute.

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?

Epi

A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm?

Epinephrine

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 receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

5% albumin

When vasoactive medications are administered, the nurse must monitor vital signs at least how often?

15 min

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

60 mm Hg

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%

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?

83

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse

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

Administer an epinephrine injection.

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

Administers oxygen by nasal cannula at 2 liters per minute

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?

Adrenergic

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?

Adrenergic drugs

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

You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

Arterial blood gas (ABG) findings

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.

During the compensation stage of shock, what is the consequence of the release of catecholamine sin the skeletal muscles?

Blood supply to the skeletal muscles increases.

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

Brain

When beta-2 adrenergic receptors are stimulated which of the following occur?

Bronchioles relax

A 74-year-old male 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

Which of the following type of shock are older adults more likely to develop?

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)

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?

Circulatory (distributive)

The nurse caring for a patient post epidural anesthesia notices that the patient is beginning to evidence symptoms of shock. The nurse assesses the patient for what type of shock?

Distributed

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance?

Elevate the legs higher than the heart.

When a patient is in the compensatory stage of shock which of the following symptoms occurs?

tachycardia

You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client?

Increase myocardial contractility

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

Intubation and mechanical ventilation

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

Narrowed pulse pressure

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:

MI

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

Maintain activity restriction to bedrest.

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?

Mean arterial pressure (MAP) of 70 mm Hg

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 trandeleburg

Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock?

Modified trendelenburg

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?

Morphine

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?

Neurogenic Shock

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?

Organ damage

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula

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?

Rapid, bounding pulse

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

The difference between the systolic and diastolic pressure

Which of the following colloids is expensive but rapidly expands plasma volume?

albumin

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

anaphylactic

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

head injury

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 ozygenation

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to:

increased cardiac output

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?

morphine

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

multiple organ failure

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?

ondansetron (Zofran)

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

reduces preload

The nurse anticipates that a patient who is immunosuppressed is at the greatest risk for developing which of the following types of shock?

sepetic

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

• Lansoprazole (Prevacid) • Famotidine (Pepcid) • Ranitidine (Zantac)