Urden Ch. 26
The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia
ANS: A Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume.
The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system
ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.
A patient has been admitted in septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to find to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/sec/cm-5
ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.
A patient is being admitted in cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine
ANS: A Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock.
A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag
ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters, rapid administration of prescribed fluids, and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.
A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres
ANS: A Neurogenic shock can be caused by anything that disrupts the SNS. The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI).
A patient has been admitted in anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility
ANS: A Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.
A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss.
ANS: A The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.
The nurse is caring for a patient who was just admitted in septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh-frozen plasma. b. Obtain a serum lactate level. c. Administer epinephrine. d. Measure central venous pressure.
ANS: B According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4mmol/L
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume
ANS: B DIC results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.
A patient has been admitted in septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs
ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.
A nursing instructor is discussing the difference between primary and secondary multiple organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.
ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary MODS) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.
A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute wide spread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.
ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.
A patient has been admitted in hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure
ANS: B Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.
The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep MAP greater than 65 mm Hg. d. Administer crystalloids fluids.
ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.
A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor
ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.
A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure
ANS: B, C, D Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min, cool, pale, moist skin, weak, thready pulse, and increased right atrial pressure and pulmonary artery occlusion pressure.
A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to find to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase
ANS: C Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism
A patient has been admitted in anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE) mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response
ANS: C IgE is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs.
A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to find to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels
ANS: C Low platelet count and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of DIC. DIC does not affect serum glucose levels.
A patient is being admitted from the emergency department (ED) in cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intra-aortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)
ANS: C Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intra-aortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation.
The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due tovinfection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)
ANS: C When SIRS is the result of infection, it is referred to as sepsis.
A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes. b. Lack of food ingestion leads to intestinal hypomotility. c. Hypoperfusion results in loss of gut barrier function. d. Low cardiac output causes decreased hydrochloric acid secretion.
ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and MODS.
The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to find to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index
ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2
A patient with known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administered first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine
ANS: D Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.
