Deck 81: Management of Clients with Shock and Multisystem Disorders

Question 1

Distributive shock is primarily due to

A) a fluid shift from the vascular space.
B) an increase in the size of the vascular space.
C) inadequate circulating blood volume.
D) inadequate pumping action of the heart.

Answer 1

an increase in the size of the vascular space.

Question 2

A client with SIRS is being treated with drotrecogin alfa (Xigris). The client exhibits a decrease in level of consciousness. Which action by the nurse is most important?

A) Increase the rate of IV infusion.
B) Notify the physician.
C) Order a stat ECG.
D) Take a set of vital signs.

Answer 2

Notify the physician.

Question 3

A client has been in a motor vehicle accident and sustained significant injuries. The client is in shock and is semi-conscious, but is restless and moaning. The family is concerned the client is in pain and demands the nurse administer ordered morphine. The priority action by the nurse is to

A) check the client's oxygen saturation.
B) give morphine as ordered, slowly.
C) politely decline their request.
D) reposition the client.

Answer 3

check the client's oxygen saturation.

Question 4

The nurse closely assesses clients who experience crushing injuries and are in shock because they are more prone than other clients to develop

A) adult respiratory distress syndrome.
B) disseminated intravascular clotting.
C) fat emboli and respiratory distress.
D) uncompensated metabolic alkalosis.

Question 5

The nurse assessing acutely ill clients who are at risk for multiple organ dysfunction syndrome (MODS) would assess for the usual precipitating manifestation of

A) bradycardia.
B) cerebral anoxia.
C) high creatinine level.
D) hypotension.

Question 6

The nurse has formulated the nursing diagnosis Interrupted Family Processes for the family of a critically ill client in the ICU with shock. The nurse would realize that outcomes for this diagnosis may not have been met when

A) a member of the family insists on using previous coping mechanisms.
B) members of the family seem supportive of each other.
C) the family is willing to participate in decision making.
D) the nurse has to repeat information several times before it is remembered.

Question 7

A client is receiving fluid replacement for treatment of shock and the nurse assesses a central venous pressure (CVP) of 15 cm water. The nurse anticipates which of the following interventions?

A) Administration of vasoconstrictors
B) Administration of vasodilators
C) Decreasing fluid infusion
D) Increasing fluid infusion

Question 8

During the progressive stage of shock, lactic acidosis occurs, resulting in

A) arterial pooling in the periphery.
B) constriction of the microcirculation.
C) increased capillary permeability.
D) movement of fluid into the capillaries.

Question 9

A client is at risk for MODS. In caring for this client, the nurse should place the highest priority on

A) assisting with incentive spirometry.
B) hourly monitoring of urinary output.
C) maintaining adequate oral intake.
D) performing range-of-motion exercises.

Question 10

The nurse is caring for an elderly client who is receiving vasodilators as part of the treatment of shock. The alteration in care the nurse should plan for this client is to

A) ensure a patent Foley catheter.
B) keep the head of the bed flat.
C) provide oxygen by nasal cannula.
D) run IV fluids at a lower rate.

Question 11

Nursing care for a client in hypovolemic shock caused by trauma should include

A) giving narcotics for pain relief.
B) maintaining a cool environment.
C) placing the client in Trendelenburg position.
D) providing nasogastric suctioning.

Question 12

The nurse suspects that the client who has entered the emergency department with severe uterine bleeding is in the early stages of shock. The nurse's first priority is to

A) administer oxygen per nasal cannula.
B) apply super-absorbent perineal pads.
C) place the client in Trendelenburg position.
D) start an intravenous line.

Question 13

A client in hypovolemic shock has a low pulmonary capillary wedge pressure. This should indicate to the nurse that

A) fluid replacement is needed.
B) pulmonary edema may be developing.
C) resuscitative measures are adequate.
D) the client's left ventricle is failing.

Question 14

The nurse caring for a client in shock who is being mechanically hyperventilated explains that the rationale for this intervention is to

A) decrease carbon dioxide levels in the blood.
B) prevent atelectasis and respiratory failure.
C) rest the client to decrease metabolism.
D) stimulate endorphin production.

Question 15

The nurse would assess the individual in the most serious stage of shock as a

A) 22-year-old man with a falling BP.
B) 35-year-old woman with a pulse pressure of 40.
C) 50-year-old woman with a MAP of 90.
D) 60-year-old man with a pulse rate of 100.

Question 16

The nurse explains that an advantage of the use of hemoglobin-based oxygen carriers (HBOCs), such as PolyHeme and Hemopure, is that these products

A) decrease the pH of the blood.
B) do not require type and crossmatch.
C) function as packed cells at less cost.
D) increase hemoglobin.

Question 17

During treatment for shock, the client receives fluid volume replacement. The nurse determines that renal perfusion is being maintained if the urine output is at least

A)0.25 ml/kg/hour.
B)0.5 ml/kg/hour.
C)1.0 ml/kg/hour.
D)1.5 ml/kg/hour.

Question 18

A client in the ICU has shock and is getting blood glucose levels drawn and treatment with subcutaneous insulin. The client's spouse is upset seeing this and says "Now s/he's a diabetic, too?" The best response by the nurse is

A) "Blood sugar goes up with physical stress and insulin controls it, and clients seem to do better."
B) "High blood sugar is a common side effect of all these medications we are giving the client."
C) "No, no, s/he is not yet a diabetic. I hope we can prevent it by giving insulin now."
D) "Under great physical stress, blood glucose elevates and people can become diabetic."

Question 19

When a client is admitted to the emergency department with a gunshot wound to the abdomen and is experiencing severe blood loss, the nurse anticipates the initial use of

A) dextran.
B) normal saline.
C) packed red blood cells.
D) whole blood.

Question 20

A client is in shock and is receiving naloxone (Narcan). The client's sibling is an EMT and questions why the client is getting medication for "an overdose." The most appropriate response by the nurse is

A) "Because of HIPAA laws, I am not allowed to tell you about his/her care."
B) "I don't know but I can have the doctor come and speak with you."
C) "In clients with shock it helps the hypotension and cardiac output."
D) "The client may have gotten too much morphine in the emergency department."

Question 21

A client is critically ill and in shock. The large, extended family has gathered in the waiting room. Important interventions the nurse can use when working with this family include (Select all that apply)

A) allow the family to ask questions and express concerns.
B) avoid explaining a lot of equipment so as not to worry the family.
C) encourage the family to participate in decision making.
D) let the family visit the client as much as possible.
E) provide frequent explanations of what is happening with the client.

Question 22

The nurse caring for a client newly diagnosed with MODS explains that the method of providing nutrition is likely to be

A) enteral nutrition.
B) intravenous fluids.
C) oral diet.
D) parenteral nutrition.

Question 23

Primary prevention techniques the nurse can teach a community group in order to prevent shock include (Select all that apply)

A) diabetes management.
B) heart-healthy living.
C) injury prevention.
D) safe exercise.