SHOCKING chapter 11
A client is believed to be in the irreversible state of shock and is unresponsive. The family requests to stay with the patient during this time. What is the best response by the nurse? "You don't want to remember your family member this way." "We have specific visiting hours that must be adhered to." "The health care team has done all that it can, so we will clear the room so you can be with your loved one." "The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them."
"The health care team needs to do procedures to help your family member, but we will ensure you have an opportunity to spend time with them." Explanation: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided—throughout the patient's care—for the family to see, touch, and talk to the patient. However, the determination that the client is in the irreversible stage of shock can only be made retrospectively, when the client has failed to recover, so the health care team will continue to attempt interventions, possibly with experimental treatments. The engagement of a palliative care specialist and of the ethics committee may be helpful.
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? Two large-bore IVs and begin crystalloid fluids 100% oxygen via a nonrebreather mask C-spine x-rays Type and cross match
100% oxygen via a nonrebreather mask Explanation: 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.
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? Within normal limits Thready 24 Palpable
24 Explanation: 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 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? Administer recombinant human activated protein C (rhAPC) as prescribed. Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. Administer norepinephrine as prescribed.
Administer norepinephrine as prescribed. Explanation: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.
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.
Which of the following is a clinical characteristic of neurogenic shock? Bradycardia Tachycardia Cool skin Moist skin
Bradycardia Explanation: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.
The 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.
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.
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? HR, 48 bpm; BP, 90/60 mm Hg Cool, moist skin HR, 120 bpm; BP, 88/58 mm Hg Shortness of breath
HR, 48 bpm; BP, 90/60 mm Hg Explanation: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock. The other signs and symptoms are associated with hypovolemic shock.
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. Identify the cause of shock. Administer vasoconstrictive medications. Administer prophylactic packed red blood cells. Administer intravenous fluids. Monitor for changes in vital signs.
Identify the cause of shock. Administer intravenous fluids. Monitor for changes in vital signs. Explanation: Early intervention along the continuum of shock is the key to improving the client's prognosis. The nurse must systematically assess the client at risk for shock, recognizing subtle clinical signs of the compensatory stage before the client's BP drops. Early interventions include identifying the cause of shock, administering intravenous (IV) fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic imbalances or infection. In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values (e.g., base deficit and lactic acid levels). Administering vasoconstrictive medications or prophylactic packed red blood cells is not necessary as an early intervention.
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.
Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? Precompensatory Compensatory Progressive Irreversible
Irreversible Explanation: 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.
The nurse is caring for a client who develops hypotension, declining mental status, and severely decreased urinary output. Which intravenous fluid will the nurse expect to be prescribed for this client? Lactated Ringer's solution 0.9% normal saline 3% sodium chloride Dextrose 5% and 0.9% normal saline
Lactated Ringer's solution Explanation: This client is demonstrating symptoms of the progressive stage of shock, and fluid replacement is indicated. Intravenous crystalloids commonly used for resuscitation in hypovolemic shock include lactated Ringer's solution. This is an electrolyte solution that contains lactate ions which are converted to bicarbonate which helps buffer the acidosis that occurs in shock. Lactated Ringer's also most closely resembles plasma and is considered a more appropriate first choice solution over 0.9% normal saline. Even though 0.9% normal saline is an isotonic solution, large infusions may cause hypernatremia, hypokalemia, and hyperchloremic metabolic acidosis. Hypertonic crystalloid solutions such as 3% sodium chloride do not improve client outcomes and may cause unintended complications. Because of this, 3% sodium chloride is not recommended for fluid resuscitation. Dextrose 5% and 0.9% normal saline is not appropriate for fluid resuscitation.
The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered? Levophed Dobutrex Nipride Methotrexate
Levophed Explanation: The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.
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? Septic Anaphylactic Neurogenic Cardiogenic
Neurogenic Explanation: The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.
In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? Nitroprusside Dopamine Epinephrine Methoxamine
Nitroprusside Explanation: A disadvantage of nitroprusside (Nipride) is that it causes hypotension. Dopamine (Intropin) improves contractility, increases stroke volume, and increases cardiac output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.
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.
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 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.
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? T3 and T4 Myoglobin and CK-MB BUN and creatinine Sodium and glucose levels
Sodium and glucose levels Explanation: In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines.
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.
The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Complete the following sentence by choosing from the lists of options. Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of -----.acute lung injury (ALI) hypermetabolic state hepatic dysfunction renal dysfunction-----. as evidenced by -----...shortness of breath a drop in blood pressure an increase in heart rate left-sided weakness
acute lung injury, shortness of breath
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.
A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? PaCO2 >45 mm Hg compensatory respiratory alkalosis heart rate <100 bpm metabolic acidosis
compensatory respiratory alkalosis Explanation: In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid. PaCO2 >45 mm Hg, is an expected finding in the progressive state of shock.
A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels? distributive cardiogenic hypovolemic organ failure
distributive Explanation: Distributive shock results from displacement of blood volume, creating pooling of blood in the peripheral blood vessels. Cardiogenic shock results from the failure of a heart as a pump. With hypovolemic shock, there is a decrease in the intravascular volume. Organ failure is not a type of shock.
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. Vital signs Nutrition Skin color Gait Urine output Peripheral pulses
vital sign skin color urine output peripheral pulses 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.