Chapter 14: Shock and Multiple Organ Dysfunction Syndrome

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

B. A myocardial infarction Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

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. "Infuse I.V. fluids at 83 ml/hour." B "Administer oxygen by nasal cannula at 3 L/minute." C. "Monitor urine output every hour." D. "Draw samples for hemoglobin and hematocrit every 6 hours."

A. "Infuse I.V. fluids at 83 ml/hour." 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 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. 5.5 mL/hr C. 8.0 mL/hr D. 11 mL/hr.

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

Which blood pressure (BP) reading would result in a pulse pressure indicative of shock? A. 90/70 mm Hg B. 120/90 mm Hg C. 100/60 mm Hg D. 130/90 mm Hg

A. 90/70 mm Hg Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. A normal 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. A BP reading of 90/70 mm Hg indicates a narrowing pulse pressure.

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. Measure urine output every hour. B. Use an intravenous controller or pump. C. Administer through an intact peripheral line. D. Verify dosage and pump settings with another RN. E. Assess vital signs every hour.

A. Measure urine output every hour. B. Use an intravenous controller or pump. D. Verify dosage and pump settings with another RN. It is recommended to administer vasoactive drugs, such as dopamine (Inotropin), 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 is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers A. A continuous infusion of total parenteral nutrition B. A full liquid diet C. An infusion of crystalloids at an increased rate of flow D. Isotonic enteral nutrition every 6 hours

A. A continuous infusion of total parenteral nutrition 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.

Which positioning strategy should be used for a client diagnosed with hypovolemic shock? A. Modified Trendelenburg B. Semi-Fowler C. Supine D. Prone

A. Modified Trendelenburg A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

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? A. Lactated Ringer's B. Albumin C. 0.9% sodium chloride D. Dextran

A. Lactated Ringer's Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

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

A. Oxygen at 2 L/min by nasal cannula 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.

A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? A. Type and cross match B. 100% oxygen via a nonrebreather mask C. Two large-bore IVs and begin crystalloid fluids D. C-spine x-rays

B. 100% oxygen via a nonrebreather mask 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 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 via a nonrebreather mask. The other orders should be completed after the client's airway is secure.

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

B. Administers oxygen by nasal cannula at 2 liters per minute 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.

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

B. Anaphylactic 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.

A client is scheduled for computed tomography (CT) scanning of the abdomen and reports an allergy to iodine. The best action of the nurse is to A. Inform the ordering physician that the CT scan cannot be performed. B. Ask the client "How does your allergy manifest itself?" C. Notify the radiologist of the allergy to iodine. D. Send the client for the CT scan, noting the allergy to iodine on the front of the chart.

B. Ask the client "How does your allergy manifest itself?" The nurse must assess the client for reactions to contrast agents. This would include the type of reaction. The nurse then communicates this information to the staff involved in the care of the client.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? A. Hypovolemic B. Circulatory (distributive) C. Carcinogenic D. Obstructive

B. Circulatory (distributive) 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.

The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? A. Place a cool compress on head. B. Elevate the legs higher than the heart. C. Cover the client with a blanket. D. Shake the client to arouse.

B. Elevate the legs higher than the heart. The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.

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 in arterial oxygenation 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.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? A. Avoid heavy meals. B. Maintain activity restriction to bedrest. C. Limit interaction with visitors. D. Arrange personal care supplies nearby.

B. Maintain activity restriction to bedrest. 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.

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. Hydromorphone B. Morphine C. Meperidine D. Codeine

B. Morphine 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.

Cardiogenic shock is most commonly seen in which patient population? A. Head injury B. Myocardial infarction C. Spinal cord injury D. Stroke

B. Myocardial infarction Cardiogenic shock is seen most often in patient with myocardial infarction.

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

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

B. Sodium and glucose levels 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. Respiratory acidosis B. Tachycardia C. Urine output of 45 cc/hour D. Bradycardia

B. Tachycardia The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

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. WBC: 42,000/mm3 C. ESR: 19 mm/hour D. Hemoglobin: 14.2 g/dL

B. WBC: 42,000/mm3 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 client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. A. GERD B. acute respiratory distress syndrome C. disseminated intravascular coagulation D. hypoglycemia E. kidney failure

B. acute respiratory distress syndrome C. disseminated intravascular coagulation E. kidney failure 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 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. nausea B. heart fails as effective pump C. peripheral vascular dilation D. blunt force trauma E. blood volume decreases

B. heart fails as effective pump C. peripheral vascular dilation E. blood volume decreases 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).

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

B. increase cardiac output. 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.

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. Hypovolemic B. Obstructive C. Circulatory (distributive) D. Cardiogenic

C. Circulatory (distributive) 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.

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess A. Skin perfusion B. Mental status C. Lung sounds D. Bowel sounds

C. Lung sounds The nurse must monitor the client during fluid replacement for side effects and complications. The most common and serious side effects include cardiovascular overload and pulmonary edema, which would be exhibited as adventitious lung sounds. Other assessments that the nurse would make include skin perfusion, changes in mentation, and bowel sounds.

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

C. The patient has developed a stress ulcer that is bleeding. 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.

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. Neurogenic B. Cardiogenic C. Anaphylactic D. Septic

D. Septic 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.

The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock? A. Neurogenic B. Cardiogenic C. Anaphylactic D. Septic

D. Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with disease of the heart. Anaphylactic shock is associated with hypersensitivity reactions.

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. 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.

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 norepinephrine as prescribed. B. Begin a continuous IV infusion of insulin per protocol. C. Initiate enteral feedings as prescribed. D. Administer recombinant human activated protein C (rhAPC) as prescribed.

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

A. Albumin 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.

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

A. Increase the force of myocardial contraction 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.

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. Ranitidine C. Furosemide D. Famotidine (Pepcid) E. Desmopressin

A. Lansoprazole B. Ranitidine D. Famotidine (Pepcid) 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. Desmopressin (DDVAP) is used in the treatment of diabetes insipidus. Furosemide (Lasix) is a loop diuretic and does not prevent ulcer formation.

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

A. Nitroprusside A disadvantage of nitroprusside is that it causes hypotension. Dopamine and epinephrine improve contractility, increase stroke volume, and increase cardiac output. Methoxamine increases blood pressure by vasoconstriction.

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) A. Vital signs B. Urinary output C. Visual acuity D. Mental status E. Ability to perform range of motion exercises

A. Vital signs B. Urinary output D. Mental status Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.

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. administer pantoprazole IV daily B. institute vital signs every 4 hours C. monitor urine output every hour D. obtain a urine specimen for culture E. maintain the IV site inserted on admission

A. administer pantoprazole IV daily C. monitor urine output every hour D. obtain a urine specimen for culture 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.

Organ failure associated with multiple organ dysfunction syndrome (MODS) usually begins in the A. lungs. B. brain. C. liver. D. kidneys.

A. lungs. During MODS, organ failure usually starts with the lungs. Next is the liver, after that the GI tract, followed by the kidneys

Older adults with impaired cardiac function are more likely to develop which type of shock? A. Anaphylactic shock B. Neurogenic shock C. Cardiogenic shock D. Septic shock

C. Cardiogenic shock Older adults, particularly those with decreased cardiac function, are prone to cardiogenic shock. Typically, underlying causes of septic shock is circulatory in nature and caused by infection, neurogenic shock occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation, and anaphylactic shock is caused by a severe allergic reaction.

You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client? A. Decreases carbon dioxide exchange B. Increases myocardial contractility C. Decreases blood return to the heart D. Contracts bronchioles

B. Increases myocardial contractility To compensate in shock, the sympathetic nervous system releases endogenous catecholamines, adrenaline and noradrenaline, into the circulation. Adrenaline and noradrenaline increase heart rate and myocardial contractility, which may be counterproductive in cardiogenic shock because it increases a demand for oxygen by an already compromised heart. Venous return to the right atrium subsequently increases, as does blood sent to the lungs. Bronchial dilatation increases the amount of oxygenated air entering the lungs, followed by a more efficient exchange of oxygen and carbon dioxide (CO2).

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 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.

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. Positive increase in the fluid balance ratio B. Jugular venous distention C. Vesicular breath sounds D. Decreased pulse rate to 110 beats/minute

B. Jugular venous distention 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.

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. Nutrition B. Urine output C. Vital signs D. Peripheral pulses E. Gait F. Skin color

B. Urine output C. Vital signs D. Peripheral pulses F. Skin color

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

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

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. 6% dextran C. 5% albumin D. 6% hetastarch

C. 5% albumin 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.

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. 60% C. 70% D. 80%

C. 70% 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%.

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? A. Hormone antagonist drugs B. Antimetabolite drugs C. Adrenergic drugs D. Anticholinergic drugs

C. Adrenergic drugs Adrenergic drugs are the main medications used to treat shock.

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. Troponin levels less than 0.35 ng/mL C. Adventitious breath sounds D. Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute

C. Adventitious breath sounds 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.

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing? A. Irreversible stage B. Progressive stage C. Compensatory stage D. Initial stage

C. Compensatory stage In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.

Oliguria occurs in the progressive stage of shock because the kidneys decompensate. Which of the following are signs or symptoms that indicate decompensation? Select all that apply. A. A mean arterial blood pressure of 70 mm Hg B. Bradycardia with a heart rate of 60 beats/min C. Decreased capillary permeability and fluid and electrolyte shifts D. Increased blood urea nitrogen and serum creatinine E. Acid-base imbalance

C. Decreased capillary permeability and fluid and electrolyte shifts D. Increased blood urea nitrogen and serum creatinine E. Acid-base imbalance In decompensation, the MAP would be less than 65 mm Hg, and the heart rate would be tachycardic or erratic with instances of asystole.

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

C. Head injury 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 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. loperamide B. meperidine C. ondansetron D. magnesium hydroxide

C. ondansetron An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

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

C. sodium nitroprusside. 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.

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 your loved one is not responding and brain dead." B. "The client is in shock because the heart is unable to circulate the body fluids." C. "The client is in shock because all peripheral blood vessels have massively dilated." D. "The client is in shock because the blood volume has decreased in the system."

D. "The client is in shock because the blood volume has decreased in the system." 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.

The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? A. Palpable B, Within normal limits C. Thready D. 24

D. 24 The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24. The pulse pressure does not report quality of the pulse.

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? A. 500 mL B. 600 mL C. 400 mL D. 300 mL

D. 300 mL An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria.

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. Irreversible C. Initial D. Compensatory

A. Progressive 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.

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

A. Parasympathetic 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.

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. Compensatory C. Refractory D. Irreversible

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

A. Anaphylactic shock; nuts B. Septic shock; infection C. Hypovolemic shock; blood loss F. Cardiogenic shock; myocardial infarction 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 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. Aortic insufficiency B. Hypertension C. Diabetes mellitus D. Unstable angina pectoris

A. Aortic insufficiency 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 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. Assess the client who is at risk for shock. B. Administer prophylactic packed red blood cells to clients at risk for shock. C. Administer vasoconstrictive medications to clients at risk for shock. D. Administer intravenous fluids. E. Monitor for changes in vital signs.

A. Assess the client who is at risk for shock. B. Administer prophylactic packed red blood cells to clients at risk for shock. E. Monitor for changes in vital signs. arly 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.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: A. Constrict blood vessels in the cardiorespiratory system. B. Vasodilate the skeletal muscles. C. Decrease heart rate. D. Relax the bronchioles.

A. Constrict blood vessels in the cardiorespiratory system. Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

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. Decompensation B. Early C. Compensation D. Irreversible

A. Decompensation 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, options A, B, and C are incorrect.

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.

A. Encourage the family to touch and talk to the client. 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.

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

A. HR, 48 bpm; BP, 90/60 mm Hg 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.

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. Assesses the client's blood glucose level C. Maintains the head of the bed at 30 degrees D. Administers a bolus of intravenous (IV) fluids

A. Lays the client flat with the feet elevated 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.

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

A. Restores blood pressure The renin-angiotensin-aldosterone systemis 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 nursing instructor is discussing shock with the senior nursing students. The instructor tells the students that shock is a life-threatening condition. What else should the instructor tell the students about shock? A. It causes respiratory distress syndrome. B. It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. C. It is a component of any trauma. D. It begins when peripheral blood flow is inadequate.

B. It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Respiratory distress syndrome can be a complication of shock but is not necessarily caused by shock. Shock does not begin when peripheral blood flow is inadequate. Not every trauma victim goes into shock.

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? A. Dextran B. Hypertonic saline C. Albumin D. Lactated Ringer solution

C. Albumin 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 with crystalloid solutions. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is A. An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection B. A middle-aged woman with metastatic breast cancer and a BMI of 26 C. An older adult man with end-stage renal disease and an infected dialysis access site D. A young female adolescent who developed shock from tampon use during menses

C. An older adult man with end-stage renal disease and an infected dialysis access site MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.

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. Radial artery C. Aorta D. Brachial artery

C. Aorta 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.

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? A. Guaifenesin (Robitussin) B. Pseudoephedrine (Sudafed) C. Diphenhydramine (Benadryl) D. Loperamide (Imodium)

C. Diphenhydramine (Benadryl) A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? A. Stevens-Johnson syndrome from the administration of antibiotics B. Septicemia C. Disseminated intravascular coagulation (DIC) D. Stress ulcer

C. Disseminated intravascular coagulation (DIC) Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.

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. Urine output of 0.2 mL/kg/hr C. Mean arterial pressure of 70 mm Hg D. Central venous pressure of 6 mm Hg

C. Mean arterial pressure of 70 mm Hg 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%.

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. Semi-Fowler's B. Supine C. Modified Trendelenburg D. Trendelenburg

C. Modified Trendelenburg 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.

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? A. Decrease in respiratory rate B. Increase in systolic blood pressure C. Narrowed pulse pressure D. Increase in diastolic pressure

C. Narrowed pulse pressure 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. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.

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. Compensatory B. Irreversible C. Progressive D. Refractory

C. Progressive 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.

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. Compensatory b. Hypovolemic C. Progressive D. Neurogenic

C. Progressive 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.

You are talking with the family of a client who is in the irreversible stage of shock. They ask you why the physician has told the family that the client is going to die. What would you explain to this family? A. The client has lost too much blood. B. The client is brain dead. C. The client is not responding to medical interventions. D. The client has given up.

C. The client is not responding to medical interventions. The irreversible stage occurs when significant cells and organs become damaged. The client's condition reaches a "point of no return" despite treatment efforts. The client no longer responds to medical interventions. Multiple systems begin to fail. When the kidneys, heart, lungs, liver, and brain cease to function, death is imminent. Options A, B. and D are not indicated in the scenario, and therefore, are incorrect.

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately? A. The client's respiratory rate is less than 20 breaths per minute. B. The client exhibits an increased urinary output. C. The client's heart rate is greater than 90 beats per minute. D. The client feels restless and hungry.

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

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 an apical and radial pulse B. The difference between the arterial and venous blood pressure C. The difference between the systolic and diastolic pressure D. The difference between an upper extremity and lower extremity blood pressure

C. The difference between the systolic and diastolic pressure The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

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. Bilateral pedal pulses are 1+. B. Vesicular breath sounds are audible in the lung periphery. C. The right foot is cooler than the left foot. D. The balloon deflates prior to systole.

C. The right foot is cooler than the left foot. 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 priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? A. Administer prophylactic antibiotics for all patients at risk. B. Insert indwelling catheters for incontinent patients. C. Use strict hand hygiene techniques. D. Have patients wear masks in the health care facility.

C. Use strict hand hygiene techniques. The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques. Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections.

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. hypovolemic shock B. septic shock C. neurogenic shock D. anaphylactic shock

C. neurogenic shock 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.

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. Cardiotonic B. Restrictive C. Hypervolemic D. Distributive

D. Distributive 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.

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. A. 70 mm Hg B. 80 mm Hg C. 90 mm Hg D. 60 mm Hg

D. 60 mm Hg Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients. The formula for calculating MAP is (2 × diastolic + systolic × 3).

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

D. A rapid, bounding pulse 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.

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: A. Breath sounds. B. Heart rate. C. Renal output. D. Blood pressure.

D. Blood pressure. By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.

Which of the following is a clinical characteristic of neurogenic shock? A. Cool skin B. Tachycardia C. Moist skin D. Bradycardia

D. Bradycardia 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.

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? A. Kidneys B. Lungs C. Liver D. Brain

D. Brain The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.

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. Cardiogenic B. Circulatory C. Progressive D. Compensatory

D. Compensatory 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.x

At what point in shock does metabolic acidosis occur? A. Compensation B. Irreversible C. Early D. Decompensation (Progressive)

D. Decompensation (Progressive) 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.

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

D. Decreased blood pressure. A potentially serious side effect of IV nitroglycerin (Tridil) is hypotension. Blood pressure needs to be monitored frequently acco

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. Benadryl B. Prednisone C. Proventil D. Epinephrine

D. Epinephrine 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.

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. Antiduretic and corticosteroid hormones are released at the beginning of the irreversible stage. C. Shock begins in the decompensation stage. D. In the compensation stage, catecholamines are released.

D. In the compensation stage, catecholamines are released. 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.

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? A. Precompensatory B. Compensatory C. Progressive D. Irreversible

D. Irreversible 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, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

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. Anaphylactic B. Septic C. Cardiogenic D. Neurogenic

D. Neurogenic 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.