Shock Exam 4

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

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

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

Crackles Decreased urine output A heart rate of 120 beats/min The clinical presentation of a patient with early septic shock includes crackles, decreased urine output, and tachycardia. Coma and cool and mottled skin occur with late septic shock.

A patient is suspected of having septic shock. Which findings would the nurse expect to observe when assessing this patient? Select all that apply. Select all that apply Some correct answers were not selected Rhonchi Crackles Cyanosis Hyperventilation Decreased urine output

Crackles Hyperventilation Decreased urine output

Which considerations would the nurse recall when administering vasopressin to a patient with septic shock? Select all that apply. Select all that apply Some correct answers were not selected Do not titrate. Infuse at low doses. Do not use with inotropic agents. Use in vasopressor-refractory patients. Do not use in patients with coronary artery disease.

Do not titrate. Infuse at low doses. Use in vasopressor-refractory patients.

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

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

Which laboratory levels would the nurse expect when caring for a patient with severe hemorrhage? Select all that apply. Increased lactate Increased sodium Decreased hematocrit Decreased blood glucose Increased natriuretic peptide

Increased lactate Decreased hematocrit

When examining a patient with septic shock, which symptoms would the nurse expect to find? Select all that apply. Select all that apply Some correct answers were not selected Paralytic ileus Pulsus paradoxus Distended jugular vein Decreased urinary output Gastrointestinal (GI) bleeding

Paralytic ileus Decreased urinary output Gastrointestinal (GI) bleeding

Which conditions can cause hypovolemic shock? Select all that apply. Select all that apply Some correct answers were not selected Ruptured spleen Valvular stenosis Bowel obstruction Diabetes insipidus Tension pneumothorax

Ruptured spleen Bowel obstruction Diabetes insipidus

Which types of shock may cause reduced urinary output in a patient? Select all that apply. Septic Obstructive Neurogenic Cardiogenic Hypovolemic Anaphylactic

Septic Obstructive Cardiogenic Hypovolemic Decreased urine output is a clinical manifestation of septic, hypovolemic, obstructive, and cardiogenic shock. Neurogenic shock is associated with bladder dysfunction. Anaphylactic shock is associated with urinary incontinence.

When managing a patient with shock, which actions would the nurse take as part of nutritional therapy? Select all that apply. Select all that apply Start enteral nutrition within the first 24 hours. Wait until the patient recovers to start with enteral nutrition. Start parenteral nutrition if enteral feedings are contraindicated. Start a slow continuous drip of small amounts of enteral feedings. Plan enteral feeding to meet at least 50% of calorie requirements.

Start enteral nutrition within the first 24 hours. Start parenteral nutrition if enteral feedings are contraindicated. Start a slow continuous drip of small amounts of enteral feedings.

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

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