Shock
12. The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock? A. Elevated systolic blood pressure B. Elevated mean arterial pressure (MAP) C. Shallow, rapid respirations D. Bradycardia
C. Shallow, rapid respirations Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.
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? "The client is in shock because the blood volume has decreased in the system." "The client is in shock because the heart is unable to circulate the body fluids." "The client is in shock because your loved one is not responding and brain dead." "The client is in shock because all peripheral blood vessels have massively dilated."
"The client is in shock because the blood volume has decreased in the system." Explanation: 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.
Hypovolemic shock is characterized by decreased intravascular volume. The nurse understands that shock would occur if the intravascular volume decreased by 15% to 25%. Therefore, for a 70 kg adult, hypovolemic shock would occur with a minimum intravascular volume of: 3 to 5.1 L. 3.5 to 5.5 L. 3.75 to 5.5 L. 3.8 to 5.8 L.
3 to 5.1 L. Explanation: The normal intravascular volume is 4 to 6 L. A reduction of 15% to 25% represents a loss of a minimum of 600 mL (4L @ 15%) to a maximum of 1,500 mL (6L @ 25%). Therefore 4,000 to 6,000 mL minus 600 to 1,500 mL = 3 to 5.1 L.
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? Blood products 5% albumin 6% dextran 6% hetastarch
5% albumin Explanation: 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? 40% 50% 60% 70%
70% Explanation: 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%.
2. In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances? A. Fluid volume circulating in the blood vessels decreases. B. There is an uncontrolled increase in cardiac output. C. Blood pressure regulation becomes irregular. D. The client experiences tachycardia and a bounding pulse.
A. Fluid volume circulating in the blood vessels decreases. Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer? A. Lactated Ringer B. Albumin C. Dextran D. 3% NaCl
A. Lactated Ringer Rationale: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringer and 0.9% sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock. The 3% NaCl is a hypertonic solution and is not isotonic.
The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion? A. The client is in the compensatory stage of shock. B. The client is in the progressive stage of shock. C. The client will stabilize and be released by tomorrow. D. The client is in the irreversible stage of shock.
A. The client is in the compensatory stage of shock. Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often-described "fight or flight" response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the client's chance of survival is low and he will certainly not be released within 24 hours. If the client were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.
A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next Administers oxygen by nasal cannula at 2 liters per minute Re-assesses the vital signs Contacts the admitting physician Calls the Rapid Response Team
Administers oxygen by nasal cannula at 2 liters per minute 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.
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 change in apical pulse rate from 102 to 88 beats/min Adventitious breath sounds Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute Troponin levels less than 0.35 ng/mL
Adventitious breath sounds Explanation: 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.
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? Liver Kidneys Lungs Brain
Brain Explanation: 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.
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? Hypervolemic Distributive Restrictive Cardiotonic
Distributive
You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Serum thyroid level findings Arterial blood gas (ABG) findings Red blood cells (RBCs) and hemoglobin count findings White blood cell count findings
Arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.
The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock? A. Increased hunger B. Decreased thirst C. Decreased urinary output D. Increased capillary perfusion
C. Decreased urinary output Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.
The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention? A. Reviewing the cause of shock and prioritizing the client's psychosocial needs B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C. Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive D. Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock
B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care Rationale: Nursing care of clients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of clients in shock; thus, suspecting that a client may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.
A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem? A. Blood is shunted from vital organs to peripheral areas of the body. B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. Rationale: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells do not have an adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.
A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock
B. Neurogenic shock Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug? A. The drug should be discontinued immediately after blood pressure increases. B. The drug dose should be tapered down once vital signs improve. C. The client should have arterial blood gases drawn every 10 minutes during treatment. D. The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.
B. The drug dose should be tapered down once vital signs improve. Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but draws every 10 minutes are not the norm.
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: Breath sounds. Blood pressure. Renal output. Heart rate.
Blood pressure. Explanation: 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.
The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs? A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements D. The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea
C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements Rationale: Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.
The nurse is caring for a 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop? Cardiogenic shock Neurogenic shock Septic shock Anaphylactic shock
Cardiogenic shock Explanation: Cardiogenic shock occurs when the heart's ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. Older adults, particularly those with cardiac disease, are susceptible to cardiogenic shock. Older adults are not susceptible to developing neurogenic, septic, or anaphylactic shock.
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Obstructive Hypovolemic Carcinogenic Circulatory (distributive)
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.
You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock? Circulatory (distributive) Cardiogenic Hypovolemic Obstructive
Circulatory (distributive) Explanation: 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.
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? Initial stage Compensatory stage Progressive stage Irreversible stage
Compensatory stage Explanation: 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.
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A. Increased urine output B. Decreased heart rate C. Hyperactive bowel sounds D. Cool, clammy skin
D. Cool, clammy skin Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal? A. Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. B. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Rationale: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the health care provider updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.
At what point in shock does metabolic acidosis occur? Late Irreversible Early Decompensation (Progressive)
Decompensation (Progressive) Explanation: 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.
What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client? Reduced preload. Reduced afterload. Increased cardiac output. Decreased blood pressure.
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.
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury Myocardial infarction Diabetes Multiple sclerosis
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.
You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? Shock begins in the decompensation stage. In the compensation stage, catecholamines are released. Antidiuretic and corticosteroid hormones are released at the beginning of the irreversible stage. The renin-angiotensin-aldosterone system fails in the compensation stage.
In the compensation 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.
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? Trendelenburg Semi-Fowler's Supine Modified Trendelenburg
Modified Trendelenburg Explanation: 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? Increase in diastolic pressure Decrease in respiratory rate Increase in systolic blood pressure Narrowed pulse pressure
Narrowed pulse pressure Explanation: 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.
A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? Liver dysfunction Organ damage Weight loss Unsteady gait
Organ damage Explanation: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.
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: Morphine 2 mg intravenously Oxygen at 2 L/min by nasal cannula NS at 60 mL/hr via an intravenous line Dopamine (Intropin) intravenous solution
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.
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? Decreases peripheral blood flow Increases catecholamine secretion Increases the production of antidiuretic hormone Restores blood pressure
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.
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? Refractory Compensatory Irreversible Progressive
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 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? Initial Compensatory Progressive Irreversible
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.
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? Inform the client's family immediately that the client will likely not survive. Closely monitor fluid replacement therapy. Provide opportunities for the family to spend time with the client, and help them to understand the irreversible stage of shock. Protect the client's airway, optimize intravascular volume, and initiate the early rehabilitation process.
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 client has a pulse rate of 142 beats per minute and a blood pressure of 70/30. To promote venous return, the nurse Elevates the head of the client's bed Raises the foot of the client's bed Turns the client to a side-lying position Places the client in a Trendelenburg position
Raises the foot of the client's bed Explanation: The description of the client is that of a person experiencing shock. In addition to administering fluids to a client in shock, the nurse positions the client with the legs elevated, which promotes venous blood return. Elevating the head of the bed will cause the client's blood pressure to drop even more. The Trendelenburg position will make breathing difficult and does not increase blood pressure or cardiac output. Placing the client in a side-lying position does not increase venous blood return.
Morphine sulfate has which of the following effects on the body? Reduces preload Increases preload Increases afterload No effect on preload or afterload
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 client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Septic Anaphylactic Neurogenic Cardiogenic
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.
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? The patient has developed a stress ulcer that is bleeding. The patient is having a reaction to the vasoconstricting medications. The patient has a tumor in the esophagus. The patient has bleeding esophageal varices.
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.
What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? Insert indwelling catheters for incontinent patients. Use strict hand hygiene techniques. Administer prophylactic antibiotics for all patients at risk. Have patients wear masks in the health care facility.
Use strict hand hygiene techniques. Explanation: 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.
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? Hemoglobin: 14.2 g/dL Potassium: 4.8 mEq/L WBC: 42,000/mm3 ESR: 19 mm/hour
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.
The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. a) Vital signs b) Nutrition c) Skin color d) Gait e) Urine output f) Peripheral pulses
a, c, e, f Explanation: Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.
