Shock - Adult

A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as A. Compensatory B. Circulatory C. Cardiogenic D. Progressive

A. Compensatory Explanation: The client's mentation, vital signs, and skin condition are those of a client in the compensatory stage of shock. Data are insufficient to support shock as either cardiogenic or circulatory in origin.

A client is believed to be in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse? A. "The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them." B. "You don't want to remember your family member this way." C. "The health care team has done all that it can, so we will clear the room so you can be with your loved one." D. "We have specific visiting hours that must be adhered to."

A. "The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them." Explanation: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided—throughout the patient's care—for the family to see, touch, and talk to the patient. However, the determination that the client is in the irreversible stage of shock can only be made retrospectively, when the client has failed to recover, so the health care team will continue to attempt interventions, possibly with experimental treatments. The engagement of a palliative care specialist and of the ethics committee may be helpful.

The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 μg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL D5W. IV infusion should be started at how many milliliters per hour? A. 2.7 mL/hr B. 8.0 mL/hr C. 11 mL/hr. D. 5.5 mL/hr

A. 2.7 mL/hr Explanation: The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)

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.

A. A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Explanation: 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 dependent edema and sepsis. Option C reflects hypovolemia. Option D is reflective of anaphylactic or distributive shock.

The nurse assesses a patient in compensatory shock whose lungs have decompensated. What clinical manifestations would the nurse expect to find? (Select all that apply.) A. A heart rate >100 bpm B. Lethargy and mental confusion C. Crackles D. Respirations <15 breaths/min E. Compensatory respiratory acidosis

A. A heart rate >100 bpm B. Lethargy and mental confusion C. Crackles Explanation: In compensatory shock, the heart rate is >100 bpm, the patient experiences lethargy and mental confusion, respirations are >20 breaths/min (not <15), and respiratory alkalosis is present (not respiratory acidosis). Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow. Crackles are heard over the lung fields.

The nurse caring for the patient in shock recognizes which physiologic responses that are common to all shock states? (Select all that apply.) A. Activation of the inflammatory response B. Must produce energy through anaerobic metabolism C. Increased intravascular volume D. Increase in cellular activity E. Hypoperfusion of tissues

A. Activation of the inflammatory response B. Must produce energy through anaerobic metabolism E. Hypoperfusion of tissues Explanation: Regardless of the initial cause of shock, certain physiologic responses are common to all types of shock. These physiologic responses include hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response. The body responds to shock states by activating the sympathetic nervous system and mounting a hypermetabolic and inflammatory response. Failure of compensatory mechanisms to effectively restore physiologic balance is the final pathway of all shock states and results in end-organ dysfunction and death. In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidotic intracellular environment. Because of these changes, normal cell function ceases (Fig. 14-1). The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell.

The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Complete the following sentence by choosing from the lists of options. Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of ______A______ as evidenced by ___B___. A. Renal Dysfunction, Acute lung injury, hypermetabolic state, hepatic dysfunction B. A drop in blood pressure, shortness of breath, an increase in heart rate, left-sided weakness

A. Acute lung Injury B. SOB Explanation: In multiple organ dysfunction syndrome (MODS), the sequence of organ dysfunction varies depending on the client's primary illness and comorbidities before experiencing shock; however, the lungs are often the first organ to show dysfunction. The client who is at risk for MODS should be assessed for the first symptom that often accompanies this diagnosis, which is acute lung injury (ALI). Symptoms associated with ALI include shortness of breath (i.e., dyspnea) and respiratory failure. Although the first presentation of MODS is often ALI, the client is also at risk for developing a hypermetabolic state, hepatic dysfunction, and renal dysfunction. Although the client may experience a drop in blood pressure and an increased heart rate with MODS, the heart and circulatory system are not affected first by this diagnosis. Left-sided weakness is associated with a right-sided stroke and not MODS.

Which colloid is expensive but rapidly expands plasma volume? A. Albumin B. Hypertonic saline C. Dextran D. Lactated Ringer solution

A. Albumin Explanation: 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 solution and hypertonic saline are crystalloids, not colloids.

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. Hypovolemic C. Obstructive D. Carcinogenic

A. Circulatory (distributive) Explanation: 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 subcategories.

A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? A. Control the shivering. B. Place the client on a warming blanket. C. Keep the client dry and covered. D. Maintain the client in a supine position with legs elevated 12 inches.

A. Control the shivering Explanation: Hyperthermia may develop related to altered temperature regulation secondary to sepsis. Because the act of shivering increases body heat through the contraction of skeletal and pilomotor muscles in the skin, it is important to get the shivering under control. Use of a warming blanket would not be an appropriate intervention because this client is septic and hyperthermic. Conduction and radiation transfer heat, which would increase the client's body temperature. Keeping the client dry and covered would not help this situation because measures that prevent evaporation and heat loss from radiation interfere with the loss of body heat. Supine positioning with elevated legs is appropriate for clients with ineffective peripheral tissue perfusion.

A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply. A. Dopamine B. Nitroglycerin C. Dobutamine D. Diphenhydramine E. Vasopressin

A. Dopamine Nitroglycerine C. Dobutamine E. Vasopressin Explanation: Dopamine is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It may be used with dobutamine and nitroglycerin to improve tissue perfusion. Dobutamine produces inotropic effects by stimulating myocardial beta-receptors, increasing the strength of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance. Intravenous nitroglycerin in low doses acts as a venous vasodilator and reduces preload. At higher doses, nitroglycerin causes arterial vasodilation and reduces afterload as well. These actions, in combination with dobutamine, increase cardiac output while minimizing cardiac workload. In addition, vasodilation enhances blood flow to the myocardium, improving oxygen delivery to the weakened heart muscle. In addition, vasopressin is another agent used to manage cardiogenic shock. Diphenhydramine is indicated in anaphylactic shock rather than cardiogenic shock, and can be given intravenously to reverse the effects of histamine.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. A. Increased paCO² levels B. Decreases in liver enzymes C. Reports of chest pain D. Loss in consciousness E. Ecchymoses and petechiae

A. Increased paCO² levels C. Reports of chest pain D. Loss in consciousness E. Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activities of the liver are impaired, and liver enzymes will increase.

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? A. Lactated Ringer's solution B. 0.9% normal saline C. Dextrose 5% and 0.9% normal saline D. 3% sodium chloride

A. LR Explanation: This client is demonstrating symptoms of the progressive stage of shock, and fluid replacement is indicated. Intravenous crystalloids commonly used for resuscitation in hypovolemic shock include lactated Ringer's solution. This is an electrolyte solution that contains lactate ions which are converted to bicarbonate which helps buffer the acidosis that occurs in shock. Lactated Ringer's also most closely resembles plasma and is considered a more appropriate first choice solution over 0.9% normal saline. Even though 0.9% normal saline is an isotonic solution, large infusions may cause hypernatremia, hypokalemia, and hyperchloremic metabolic acidosis. Hypertonic crystalloid solutions such as 3% sodium chloride do not improve client outcomes and may cause unintended complications. Because of this, 3% sodium chloride is not recommended for fluid resuscitation. Dextrose 5% and 0.9% normal saline is not appropriate for fluid resuscitation.

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. Lansoprazole B. Desmopressin C. Furosemide D. Nizatidine E. Famotidine (Pepcid)

A. Lansoprazole D. Nizatidine E. Famotidine (Pepcid) Explanation: Antacids, H2 blockers (Pepcid, Axid), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.

A client admitted for outpatient surgery has been NPO for several hours. The client, sitting in bed, experiences a transient neurogenic shock following insertion of an intravenous catheter. The nurse first A. Lays the client flat with the feet elevated B. Administers a bolus of intravenous (IV) fluids C. Assesses the client's blood glucose level D. Maintains the head of the bed at 30 degrees

A. Lays the client flat with the feet elevated Explanation: The client may have fainted, which is a sign of transient neurogenic shock. To minimize pooling of blood in the legs and to restore blood flow to the brain, the nurse lays the client flat and elevates his or her feet. Another cause may be hypoglycemia. If the above action does not resolve the client's problem, the nurse should assess the client's blood glucose level. Raising the head of the bed would be done if the client had received spinal or epidural anesthesia. A bolus of IV fluids would be given if the client were dehydrated.

A nurse consults with the health care provider about inotropic agents for a client in cardiogenic shock. Which medications would improve the client's contractility? Select all that apply. A. dobutamine B. nitroprusside C. dopamine D. epinephrine E. nitroglycerin

A. dobutamine C. dopamine D. epinephrine Explanation: Dobutamine (Dobutrex), dopamine (Intropin), and epinephrine (Adrenalin) are inotropic agents used to improve client's contractility. Nitroprusside (Nipride) and nitroglycerin (Tridil) are vasodilators used to reduce preload and afterload, reducing oxygen demand in the heart.

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? Select all that apply. A. Monitor for changes in vital signs. B. Identify the cause of shock. C. Administer intravenous fluids. D. Administer prophylactic packed red blood cells. E. Administer vasoconstrictive medications.

A. Monitor for changes in vital signs. B. Identify the cause of shock. C. Administer intravenous fluids. Explanation: Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client'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.

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? A. Multiple organ failure B. Endotoxins in the system C. Limited gas exchange D. Brain death

A. Multiple organ failure Explanation: In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.

Clinical characteristics of neurogenic shock are noted by which type of stimulation? A. Parasympathetic B. Sympathetic C. Endocrine D. Cerebral

A. Parasympathetic Explanation: 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 client 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.

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. A. Place the client in modified Trandelenberg position B. Initiate an IV site and prescribed IV fluids C. Assess the capillary blood glucose level D. Collect a stool specimen for culture

A. Place the client in modified Trandelenberg position B. Initiate an IV site and prescribed IV fluids C. Assess the capillary blood glucose level D. Collect a stool specimen for culture Explanation: The nurse provides care based on Maslow's hierarchy of needs. The client in shock should be properly positioned first. Then, an IV insertion site and fluids need to be started to correct the hypovolemic shock. Because the client is diabetic, the blood glucose level needs to be assessed and treated. Finally, collection of a stool specimen will be important to assess the cause of the gastrointestinal distress.

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? Select all that apply A. Platelet count B. Blood pressure C. Bilirubin level D. Urine output E. Respiratory rate F. Cardiac rhythm

A. Platelet count B. BP C. Bilirubin level D. Urine output E Respiratory rate Explanation: Clients with a critical illness who are demonstrating signs of an infection should be monitored for the developing of sepsis using the Sepsis-Related Organ Failure Assessment Score. The parameters monitored through this score include urine output, bilirubin level, platelet count, blood pressure, and respiratory rate in addition to mean arterial pressure, serum creatinine, and Glasgow Coma Scale score. Cardiac rhythm is not a parameter used to determine the development of sepsis.

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? A. Progressive B. Refractory C. Compensatory D.Irreversible

A. Progressive Explanation: In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

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. Hypovolemic C. Compensatory D. Neurogenic

A. Progressive Explanation: 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.

The nurse, a member of the health care team in the ED, is caring for a client who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention? A. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. B. Closely monitor fluid replacement therapy. C. Inform the client's family immediately that the client will likely not survive. D. Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process.

A. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. Explanation: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the client does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the client and helping them to understand the irreversible stage of shock is the best intervention. Informing the client's family too early that the client will not survive would rob the family of hope and interrupt the grieving process. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing end-of-life issues.

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply. A. Septic shock; infection B. Neurogenic shock; diabetes C. Anaphylactic shock; nut allergy D. Cardiogenic shock; myocardial infarction E. Hypovolemic shock; blood loss F. Obstructive shock; kidney stone

A. Septic shock; infection C. Anaphylactic shock; nut allergy D. Cardiogenic shock; myocardial infarction E. Hypovolemic shock; blood loss Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interfere in blood flow through the heart . Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.

A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. A. The client who reports an allergy to peanuts that causes throat swelling B. The client who is in the first 15 minutes of receiving 1 unit of PRBCs C. The client with an infection who is prescribed intravenous vancomycin D. The client who is scheduled for a repeat CT scan of the abdomen E. The 55-year-old client with spina bifida

A. The client who reports an allergy to peanuts that causes throat swelling B. The client who is in the first 15 minutes of receiving 1 unit of PRBCs E. The 55-year-old client with spina bifida Explanation: Risk factors for anaphylactic shock include transfusion reaction, latex allergy, and severe allergy to foods or medications. The client in the first 15 minutes of receiving blood is at risk for an anaphylactic reaction. This is why the nurse should remain in the room for the first 15 minutes of infusion. The client with spina bifida is at risk for a latex allergy, which, in turn, increases the risk for an anaphylactic reaction if latex gloves are used. The client with a peanut allergy is at risk for an anaphylactic reaction if food is prepared or accidentally contaminated with a nut-based oil. The other clients are not at an increased risk for anaphylactic shock.

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? A. The patient has developed a stress ulcer that is bleeding. B. The patient has a tumor in the esophagus. C. The patient is having a reaction to the vasoconstricting medications. D. The patient has bleeding esophageal varices.

A. The patient has developed a stress ulcer that is bleeding Explanation: GI ischemia can cause stress ulcers in the stomach during the progressive stage of shock, putting the patient at risk for GI bleeding. The patient would not be on vasoconstrictors but vasodilators, to improve perfusion, and such a reaction would be unlikely. There is no indication that the patient has a tumor or varices in the esophagus.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: A. The right foot is cooler than the left foot. B. Bilateral pedal pulses are 1+. C. The balloon deflates prior to systole. D. Vesicular breath sounds are audible in the lung periphery.

A. The right foot is cooler than the left foot Explanation: When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery.

A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply. A. Use an intravenous controller or pump. B. Administer through an intact peripheral line. C. Measure urine output every hour. D. Assess vital signs every hour. E. Verify dosage and pump settings with another RN.

A. Use an intravenous controller or pump. C. Measure urine output every hour. E. Verify dosage and pump settings with another RN. Explanation: It is recommended to administer vasoactive drugs, such as dopamine (Intropin), through a central line. The nurse assesses vital signs every 15 minutes until stable. The nurse uses an intravenous controller or pump to ensure accurate infusion and verifies the dosage and pump settings with another RN. The nurse also measures urine output every hour.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. A. acute respiratory distress syndrome B. GERD C. disseminated intravascular coagulation D. hypoglycemia E. kidney failure

A. acute respiratory distress syndrome C. disseminated intravascular coagulation E. kidney failure Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

A client who experienced shock remains unstable. Which medication classes would the nurse anticipate to be ordered to prevent or minimize stress ulcers? Select all that apply. A. antacids B. H2 blockers C. proteases D. promotility agents E. proton pump inhibitors

A. antacids B. H2 blockers E. PPIs Explanation: Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, H2 blockers [e.g., famotidine (Pepcid)], and proton pump inhibitors [e.g., lansoprazole (Prevacid), esomeprazole magnesium (Nexium)] are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Proteases and peptidases split proteins into small peptides and amino acids and help with digestion. A promotility agent such as metoclopramide is used to decrease nausea, vomiting, heartburn, a feeling of fullness after meals, and loss of appetite.

A client is brought into the ED with extensive traumatic injuries. The paramedic reports that the client has "shock." What are the etiologies of shock? Select all that apply. A. heart fails as effective pump B. peripheral vascular dilation C. nausea D. blunt force trauma E. blood volume decreases

A. heart fails as an effective pump B. peripheral vascular dilation E. blood volume decreases Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock develops as a consequence of one of three events: (1) blood volume decreases, (2) the heart fails as an effective pump, or (3) peripheral blood vessels massively dilate (Wedro, 2014).

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. A. kidney failure B. GERD C. acute respiratory distress syndrome D. disseminated intravascular coagulation E. hypoglycemia

A. kidney failure C. ARDS D. disseminated intravascular coagulation Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence. The nurse should ___, ___ , and ____. A. monitor temperature B. administer oxygen therapy C. increase oral (PO) fluid intake D. obtain lactate level E. Maintain prone position

A. monitor temperature B. administer oxygen therapy D. obtain lactate level Explanation: The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.

The client was admitted to the hospital following a myocardial infarction. Two days later, the client exhibits a blood pressure of 90/58, pulse rate of 132 beats/min, respirations of 32 breaths/min, temperature of 101.8°F, and skin warm and flushed. What appropriate interventions should the nurse take? Select all that apply. A. monitor urine output every hour B. maintain the IV site inserted on admission C. institute vital signs every 4 hours D. administer pantoprazole IV daily E. obtain a urine specimen for culture

A. monitor urine output every hour D. administer pantoprazole IV daily E. obtain a urine specimen for culture Explanation: The client is exhibiting signs of septic shock. It is important to identify the source of infection, such as obtaining a urine specimen for culture. Medication, such as pantoprazole (Protonix), would be administered to prevent stress ulcers. The nurse would monitor urinary output every hour to evaluate effectiveness of therapy. IV sites would be changed and catheter tips cultured as this could be the source of infection. The client's condition warrants vital signs being assessed more frequently than every 4 hours.

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 A. sodium nitroprusside. B. dopamine. C. norepinephrine. D. furosemide.

A. sodium nitroprusside Explanation: Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine 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 is a loop diuretic that reduces intravascular fluid volume.

A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client? A. <200 mg/dL B. <180 mg/dL C. <80 mg/dL D. <60 mg/dL

B. <180 mg/dL Explanation: Tight glycemic control (serum glucose of 80 to 100 mg/dL) is no longer recommended, as hypoglycemic events associated with regulating tight control in critically ill clients have been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose levels lower than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the critically ill client.

A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client? A. <60 mg/dL B. <180 mg/dL C. <80 mg/dL D. <200 mg/dL

B. <180 mg/dL Explanation: Tight glycemic control (serum glucose of 80 to 100 mg/dL) is no longer recommended, as hypoglycemic events associated with regulating tight control in critically ill clients have been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose levels lower than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the critically ill client.

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A. Isotonic enteral nutrition every 6 hours B. A continuous infusion of total parenteral nutrition C. An infusion of crystalloids at an increased rate of flow D. A full liquid diet

B. A continuous infusion of TPN Explanation: 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.

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. A slow and imperceptible pulse B. A rapid, bounding pulse C. A slow but steady pulse D. A weak and thready pulse

B. A rapid, bounding pulse Explanation: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.

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. Re-assesses the vital signs B. Administers oxygen by nasal cannula at 2 liters per minute C. Contacts the admitting physician D. Calls the Rapid Response Team

B. Administers oxygen by nasal cannula at 2 L/min Explanation: 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.

What is the consequence of the release of catecholamines in the skeletal muscles during the compensation stage of shock? A. The liver releases glycogen to provide energy. B. Blood supply to the skeletal muscles increases. C. Blood supply to the body decreases. D. The amount of air that enters the lungs decreases.

B. Blood supply to the skeletal muscles increases Explanation: Catecholamines cause the dilatation of arterioles in the skeletal muscles that increases their blood supply. The release of catecholamines increases the heart rate and the blood supply to the body. The release of catecholamines causes bronchial dilatation to increase the amount of air that enters the lungs. Glycogen release is a consequence of the release of catecholamines in the liver, not the skeletal muscles.

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. The renin-angiotensin-aldosterone system fails in the compensation stage. B. In the compensation stage, catecholamines are released. C. Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage. D. Shock begins in the decompensation stage.

B. In the compensatory stage, catecholamines are released Explanation: 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.

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

B. Increase arterial oxygenation Explanation: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. 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.

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate? A. Slow the heart rate B. Increase the force of myocardial contraction C. Dilate the bronchial tree D. Depress the central nervous system

B. Increase the force of myocardial contraction Explanation: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? A. Thoracotomy with chest tube insertion B. Intubation and mechanical ventilation C. Administration of oxygen via venture mask D. Pericardiocentesis

B. Intubation and mechanical ventilation Explanation: 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. Pericardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? A. High B. Low C. Normal D. Unable to measure

B. Low Explanation: The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

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? A. ScvO2 of 60% B. Mean arterial pressure of 70 mm Hg C. Central venous pressure of 6 mm Hg D. Urine output of 0.2 mL/kg/hr

B. MAP of 70 mm Hg Explanation: The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure? A. Rapid, shallow respirations B. Myocardial depression C. Lethargy and confusion D. Respiratory alkalosis

B. Myocardial depression Explanation: The body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.

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. Septic B. Neurogenic C. Anaphylactic D. Cardiogenic

B. Neurogenic Explanation: 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.

The student nurse is being precepted in the ICU. The student is 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

B. Production of antidiuretic hormone and corticosteroid hormones Explanation: Antidiuretic hormone (ADH) and corticosteroid hormones play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones 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.

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. Compensatory B. Progressive C. Initial D. Irreversible

B. Progressive Explanation: 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.

A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: A. The balloon deflates prior to systole. B. The right foot is cooler than the left foot. C. Vesicular breath sounds are audible in the lung periphery. D. Bilateral pedal pulses are 1+.

B. The right foot is cooler than the left foot. Explanation: When a client has an intra-aortic balloon counterpulsation, he or she is at risk for circulatory problems in the leg in which the catheter has been inserted. In this case, it is the right leg. A complication would be a right foot that is cooler than the left foot. Pedal pulses of 1+ bilaterally would not be a complication of this therapy but of other problems. The balloon is supposed to deflate prior to systole. It is normal for vesicular breath sounds to be audible in the lung periphery.

What is the major clinical use of dobutamine? A. treat hypotension. B. increase cardiac output. C. treat hypertension. D. prevent sinus bradycardia.

B. increase cardiac output Explanation: Dobutamine (Dobutrex) 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.

A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure? A. bradycardia B. low urine output C. rapid respirations D. constipation

B. low urine output Explanation: Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP), or the average pressure at which blood moves through the vasculature. When a MAP falls below 65 mm Hg, a client with progressive shock will have decreased kidney function and low urine output. Clients with low MAP will have tachycardia, slow respirations, and bloody diarrhea.

The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate? A. 1:1 B. 2:1 C. 3:1 D. 4:1

C. 3:1 Explanation: IV fluids are prescribed to restore intravascular volume. The total volume, type of solution(s), and rate of administration vary according to the etiology of shock. Usually, a ratio of 3:1 is followed; that is, 3 L of fluid is administered for every 1 L of fluid lost.

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: A. Valvular damage. B. Arrhythmias. C. A myocardial infarction. D. Cardiomyopathies.

C. A MI Explanation: Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

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. Right ventricular wall B. Brachial artery C. Aorta D. Radial artery

C. Aorta Explanation: 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.

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? A. Unstable angina pectoris B. Hypertension C. Aortic insufficiency D. Diabetes mellitus

C. Aortic insufficiency Explanation: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? A. Reduced preload. B. Reduced afterload. C. Decreased blood pressure. D. Increased cardiac output.

C. Decreased blood pressure Explanation: A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently according to the manufacturer's recommendation and institutional policy.

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? A. Cool, moist skin B. HR, 120 bpm; BP, 88/58 mm Hg C. HR, 48 bpm; BP, 90/60 mm Hg D. Shortness of breath

C. HR, 48 bpm; BP, 90/60 mm Hg Explanation: 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.

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? A. Dobutrex B. Nipride C. Levophed D. Methotrexate

C. Levophed Explanation: The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.

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 B. Furosemide C. Nizatidine D. Lansoprazole E. Famotidine (Pepcid)

C. Niatidine D. Lansoprazole E. Famotidine (Pepcid) Explanation: Antacids, H2 blockers (Pepcid, Axid), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.

Which drug is a vasodilator used in the treatment of shock? A. Norepinephrine B. Dopamine C. Nitroglycerin D. Dobutamine

C. Nitroglycerine Explanation: Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norepinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction.

Which vasodilator medication is used in the treatment of shock? A. Dobutamine B. Dopamine C. Nitroglycerin D. Norepinephrine

C. Nitroglycerine Explanation: Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norepinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction.

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: A. NS at 60 mL/hr via an intravenous line B. Dopamine (Intropin) intravenous solution C. Oxygen at 2 L/min by nasal cannula D. Morphine 2 mg intravenously

C. Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

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. Refractory B. Irreversible C. Progressive D. Compensatory

C. Progressive Explanation: 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 client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

The nurse is caring for a client in the compensation stage of shock. One of the body's mechanisms of compensation in this stage of shock is the action of the renin-angiotensin-aldosterone system. What does this system do? A. Increases catecholamine secretion B. Increases the production of antidiuretic hormone C. Restores blood pressure D. Decreases peripheral blood flow

C. Restores blood pressure Explanation: The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. It does not decrease peripheral blood flow, increase catecholamine secretion, or increase the production of antidiuretic hormone.

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. Anaphylactic B. Neurogenic C. Septic D. Cardiogenic

C. Septic Explanation: 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.

A nurse is providing care to all of the following clients. Which client would be most at risk for septic shock? A. The client with a BMI of 25 who has lost 3 pounds as the result of vomiting B. The client with pneumonia in the left lower lobe of the lung C. The client with testicular cancer who is receiving intravenous chemotherapy D. The 45-year-old client with a sudden onset of frequent premature ventricular contractions (PVCs)

C. The client with testicular cancer who is receiving intravenous chemotherapy Explanation: Risk factors for septic shock include immunosuppression, such as with the client who has testicular cancer and is receiving chemotherapy. Other risk factors include age younger than 1 year or greater than 65 years, malnourishment, chronic illness, and invasive procedures. None of the other clients meets these risk factors or has a greater risk for invasive procedures than the client with testicular cancer.

A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? A. heart rate <100 bpm B. PaCO2 >45 mm Hg C. compensatory respiratory alkalosis D. metabolic acidosis

C. compensatory respiratory alkalosis Explanation: In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid. PaCO2 >45 mm Hg, is an expected finding in the progressive state of shock.

A 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. neurogenic shock D. hypovolemic shock

C. neurogenic shock Explanation: 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.

A client who has been brought to the ED is unresponsive, and has an 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. The client's labs show an elevated white blood cell count; cultures are forthcoming. What does the nurse suspect may be the cause of the client's present condition? A. cardiogenic shock B. anaphylactic shock C. septic shock D. neurogenic shock

C. septic shock Explanation: Septic shock occurs most commonly in clients with gram-negative bacteremia (bacteria in the blood) caused by such pathogens as Escherichia coli, species of Pseudomonas, and gram-positive drug-resistant Staphylococcus aureus and streptococcal species. Unlike other forms of shock, clients with septic shock have an elevated leukocyte count and initially manifest a fever accompanied by warm, flushed skin and a rapid, bounding pulse. Clients in anaphylactic shock do not have elevated leukocyte counts nor a fever with warm, flushed skin. Injury to the spinal cord or head or overdoses of opioids, opiates, tranquilizers, or general anesthetics can cause neurogenic shock. A myocardial infarction is the leading cause of cardiogenic shock.

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? A. Hypovolemic B. Obstructive C. Carcinogenic D. Distributive

D. Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such condition as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

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? A. Hypervolemic B. Cardiotonic C. Restrictive D. Distributive

D. Distributive Explanation: The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. Distributive, restrictive, and cardiotonic are not categories of shock.

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. "Draw samples for hemoglobin and hematocrit every 6 hours." C. "Monitor urine output every hour." D. "Infuse I.V. fluids at 83 ml/hour."

D. "Infuse I.V. fluids at 83 mL/hour." Explanation: 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.

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? A. 4 to 5 mm Hg B. 6 to 7 mm Hg C. 1 to 3 mm Hg D. 8 to 12 mm Hg

D. 8 to 12 mm Hg Explanation: The goal in colloidal fluid replacement is to achieve a central venous pressure of 8 to 12 mm Hg or higher (normal = 2 to 8 mm Hg).

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? A. Administer recombinant human activated protein C (rhAPC) as prescribed. B. Initiate enteral feedings as prescribed. C. Begin a continuous IV infusion of insulin per protocol. D. Administer norepinephrine as prescribed.

D. Administer norepinephrine as prescribed Explanation: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

Which type of shock occurs from an antigen-antibody response? A. Neurogenic B. Septic C. Cardiogenic D. Anaphylactic

D. Anaphylactic Explanation: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

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: A. Crackles and shallow breathing. B. A systolic blood pressure of 75 mm Hg. C. A heart rate of 140. D. Cold, clammy skin and tachycardia.

D. Cold, clammy skin and tachycardia Explanation: In the preshock stage, the patient begins to lose tissue perfusion but compensates initially. Therefore, early signs of shock are evident.

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? A. Irreversible B. Early C. Compensation D. Decompensation

D. Decompensation Explanation: The decompensation 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, the other answer options are incorrect.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. A.Vomiting B. Trauma C. Diarrhea D. Dehydration E. Burns

D. Dehydration E. Burns Explanation: The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is A. Packed red blood cells B. Plasma C. Salt-poor albumin D. Dextran

D. Dextran Explanation: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

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? A. Prednisone B. Benadryl C. Proventil D. Epinephrine

D. Epinephrine Explanation: Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? A. Diabetes B. Multiple sclerosis C. Myocardial infarction D. Head injury

D. Head injury Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: A. Vesicular breath sounds B. Positive increase in the fluid balance ratio C. Decreased pulse rate to 110 beats/minute D. Jugular venous distention

D. Jugular venous distention Explanation: When administering large volumes of fluid replacement, the nurse monitors the client for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. The nurse assesses for jugular vein distention. Decreased pulse rate, when the client is tachycardic as in hypovolemic shock, would indicate improvement. The client would also exhibit a positive increase in the fluid balance ratio when responding appropriately to treatment. The client should exhibit vesicular breath sounds.

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. Hydromorphone C. Meperidine D. Morphine

D. Morphine Explanation: 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.

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? A. Epinephrine B. Methoxamine C. Dopamine D. Nitroprusside

D. Nitroprusside Explanation: A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.

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: A. Morphine 2 mg intravenously B. Dopamine (Intropin) intravenous solution C. NS at 60 mL/hr via an intravenous line D. Oxygen at 2 L/min by nasal cannula

D. Oxygen at 2 L/min by NC Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

Morphine sulfate has which of the following effects on the body? A. Increases preload B. Increases afterload C. No effect on preload or afterload D. Reduces preload

D. Reduces preload Explanation: 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).

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? A. BUN and creatinine B. T3 and T4 C. Myoglobin and CK-MB D. Sodium and glucose levels

D. Sodium and glucose levels Explanation: In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.

When a client is in the compensatory stage of shock, which symptom occurs? A. Urine output of 45 mL/hr B. Bradycardia C. Respiratory acidosis D. Tachycardia

D. Tachycardia Explanation: The compensatory stage of shock encompasses a normal BP, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

How should vasoactive medications be administered? A. Intramuscularly (IM) B. By rapid intravenous (IV) push C. Through a peripheral IV line D. Using a central venous line

D. Using a central venous line Explanation: 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.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? A. Potassium: 4.8 mEq/L B. Hemoglobin: 14.2 g/dL C. ESR: 19 mm/hour D. WBC: 42,000/mm3

D. WBC: 42,000/mm3 Explanation: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

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? A. hypovolemic B. cardiogenic C. organ failure D. distributive

D. distributive Explanation: Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock.