Question 1

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 occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.
B) It causes respiratory distress syndrome.
C) It begins when peripheral blood flow is inadequate.
D) It is a component of any trauma.

Accepted Answer

Shock occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. The other options are incorrect as shock does not necessarily cause respiratory distress syndrome, it does not always begin when peripheral blood flow is inadequate, and it is not a component of any trauma, but can result from trauma in some cases.

Question 2

As the nurse, you are clients' first line of defense in treating shock. When assessing a client for early signs of shock, what would you assess first?
A) B/P, Urine output, and mentation
B) Vital signs, skin color, and temperature
C) Mental status, skin color, and dyspnea
D) Temperature, level of consciousness, and airway obstruction

Accepted Answer

Vital signs are the initial assessment parameter to determine early signs of shock. Skin color and temperature are also important indicators as they can suggest poor perfusion to the skin and tissues.

Question 3

The ICU nurse is required to closely monitor four clients diagnosed with shock. During the shift assessment, the nurse documents the following values for the clients. Which client is most stable?
A) Client A: Heart rate 70 beats per minute, systolic blood pressure (BP) 100 mm Hg, urine output 30 mL/hour
B) Client B: Capillary refill time between 7 and 10 seconds, urine output 35 mL/hour
C) Client C: Heart rate 115 beats per minute, systolic BP 129 mm Hg, urine output 60 mL/hour
D) Client D: Capillary refill time between 5 and 6 seconds, urine output 30 mL/hour

Accepted Answer

C

Question 4

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) Shock begins in the decompensation stage.
B) In the compensation stage, catecholamines are released.
C) Antiduretic and corticosteroid hormones are released at the beginning of the irreversible stage.
D) The renin-angiotensin-aldosterone system fails in the compensation stage.

Accepted Answer

The stages of shock are the initial stage, compensation stage, and the irreversible stage. In the compensation stage, the body releases catecholamines to help compensate for the decreased perfusion.

Question 5

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) Distributive
B) Cardiogenic
C) Hypovolemic
D) Obstructive

Accepted Answer

Vasodilation and a hypervolemic peripheral vascular area are both indicative of distributive shock, which occurs when there is a widespread and excessive vasodilation resulting in decreased peripheral vascular resistance and impaired tissue perfusion. The reduced central blood flow also supports this diagnosis, as there is inadequate circulation of blood to the vital organs that support the body's normal physiological functioning. Cardiogenic shock would involve a primary issue within the heart causing decreased cardiac output, hypovolemic shock would involve a loss of fluid volume, and obstructive shock would be the result of an obstruction preventing normal blood flow.

Question 6

Your client is in shock. You are to assess this client for inadequate oxygen delivery to the tissues. What is the first sign you will observe in the initial stages of shock?
A) Cyanosis
B) Decreased respiratory rate
C) Altered cerebral function
D) Increased body temperature

Accepted Answer

Altered cerebral function is often the first sign of inadequate oxygen delivery to the tissues during the initial stages of shock. This occurs because the brain is highly sensitive to changes in oxygen levels, leading to symptoms such as confusion, agitation, or lethargy.

Question 7

A client comes to the Emergency Department (ED) after a motor vehicle accident. The client is transported by the paramedics and is in a pneumatic antishock garment (PASG). As an ED nurse, you know that a PASG is used for a limited number of conditions. What would be a reason for the paramedics to put the client in a PASG?
A) Septic shock
B) To control hemorrhage and hypotension resulting from pelvic fractures
C) Intra-thoracic rupture of aorta
D) Compensation for severe hypervolemia after intra-abdominal trauma

Accepted Answer

A PASG is typically used to control hemorrhage and hypotension resulting from pelvic fractures. It applies pressure to the lower extremities to improve blood flow to vital organs and help stabilize the client's condition. It is not used for septic shock, intra-thoracic rupture of aorta, or compensation for severe hypervolemia after intra-abdominal trauma.

Question 8

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.

Accepted Answer

In the irreversible stage of shock, a client's vital organs are not responding to medical interventions, indicating that the body's systems are shutting down. At this point, it is not possible to reverse the damage that has been done, and the client is likely to die. This is why the physician has given this information to the family. The other options may also be contributing factors to the client's condition, but in the irreversible stage of shock, the client's body is no longer able to respond to medical interventions.

Question 9

You are assessing a 6-year-old little girl in the Emergency Department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?
A) She is having an allergic reaction and going into cardiogenic shock.
B) She is having an allergic reaction and going into anaphylactic shock.
C) She is having an allergic reaction and going into neurogenic shock.
D) She is having an allergic reaction and going into obstructive shock.

Accepted Answer

The symptoms described in the question suggest that the child is experiencing anaphylactic shock, which is a severe allergic reaction that can be life-threatening. Anaphylactic shock typically involves a rapid onset of symptoms, including difficulty breathing, hives, hypotension, and vasodilation. Treatment should be initiated immediately, including the use of epinephrine, antihistamines, and IV fluids. It is important to act quickly when encountering a patient with anaphylactic shock as the condition can progress rapidly and result in cardiovascular collapse.

Question 10

The nursing instructor is explaining the causes of shock. What are the causes of shock? Select all that apply.
A) Blood volume decreases.
B) Heart cannot pump blood effectively.
C) Peripheral blood vessels dilate on massive scale.
D) Venous oxygen saturation is inadequate.
E) Heart rate falls below 90.

Accepted Answer

Shock can be caused by a decrease in blood volume (hypovolemic shock), the heart's inability to pump blood effectively (cardiogenic shock), and massive dilation of peripheral blood vessels (distributive shock), which includes septic, anaphylactic, and neurogenic shock.

Question 11

Your client is in the ICU being treated for shock. The client's condition worsens as they become hypothermic and develop respiratory distress. What nursing intervention would help restore the body temperature to normal range?
A) Warm the humidified air that is mixed with oxygen during mechanical ventilation.
B) Cool the IV solutions and blood products to be administered to the client.
C) Administer a tepid sponge bath to the client.
D) Place the client on a cooling mattress.

Accepted Answer

Warming the humidified air that is mixed with oxygen during mechanical ventilation can help restore the body temperature to normal range in a client who is hypothermic. This can reduce the workload on the body to produce heat and improve respiratory distress. Cooling the fluids or administering a tepid sponge bath can further worsen the hypothermia and lead to more complications. Placing the client on a cooling mattress is also not a suitable option for hypothermia treatment.

Question 12

You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock?
A) Hypervolemic
B) Distributive
C) Restrictive
D) Cardiotonic

Accepted Answer

The different categories of shock include hypovolemic, distributive, and cardiogenic. Restrictive shock is not a recognized category of shock. Cardiotonic shock is not a recognized term.

Question 13

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

Accepted Answer

Neurogenic shock is a subcategory of distributive shock. In distributive shock, blood volume is not effectively redistributed, leading to decreased perfusion and oxygenation of vital organs. Neurogenic shock specifically occurs as a result of spinal cord injury, which can cause the loss of sympathetic nervous system function and subsequent vasodilation.

Question 14

What is the best reason for administering vasopressors after fluid therapy for a client in shock?
A) To aid better circulation and absorption of the vasopressors
B) To promote rapid metabolism and excretion of the vasopressors
C) To prevent the vasopressors from further lowering the blood pressure (BP)
D) To prevent the vasopressors from further impairing cellular circulation

Accepted Answer

The answer of What is the best reason for administering...

Question 15

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?
A) A rapid, bounding pulse
B) A slow but steady pulse
C) A weak and thready pulse
D) A slow and imperceptible pulse

Accepted Answer

In the initial stages of septic shock, the body attempts to compensate for the low blood pressure and poor circulation by increasing the heart rate, leading to a rapid, bounding pulse. This is a common physiological response to try and maintain adequate blood flow to vital organs.

Question 16

You are the nurse caring for a client with shock accompanied by lung congestion. How would you position this client?
A) Completely supine
B) Low Fowlers with legs flat
C) Supine with lower extremities raised to approximately 45º
D) Semi-Fowlers with lower extremities raised to approximately 15º

Accepted Answer

Positioning a client in semi-Fowlers with lower extremities raised to approximately 15º helps to improve lung expansion and oxygenation while also aiding venous return to the heart, which is beneficial in managing shock and lung congestion.

Question 17

The nursing instructor is discussing shock with her students. She describes the consequences of shock in the decompensation stage. What are these consequences? Select all that apply.
A) Neurologic hyperexcitability
B) Cellular hypoxia
C) Hypokalemia
D) Coagulation defects
E) Cardiovascular changes

Accepted Answer

In the decompensation stage of shock, cellular hypoxia occurs due to inadequate oxygen delivery. Coagulation defects can arise from impaired blood flow and tissue damage. Cardiovascular changes, such as decreased cardiac output and blood pressure, are also consequences of this stage.

Question 18

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?
A) Serum thyroid level findings
B) Arterial blood gas (ABG) findings
C) Red blood cells (RBCs) and hemoglobin count findings
D) White blood cell count findings

Accepted Answer

Arterial blood gas (ABG) findings would provide the best evidence of hypoxemia and metabolic acidosis, as ABGs directly measure the level of oxygen and carbon dioxide in the blood as well as the pH and bicarbonate levels, which indicate acid-base balance. Serum thyroid level findings, RBCs and hemoglobin count findings, and white blood cell count findings would not provide specific evidence of hypoxemia or metabolic acidosis in a client with shock.

Question 19

You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the reabsorption and retention of fluid in the body?
A) Activation of renin-angiotensin-aldosterone system
B) Secretion of epinephrine and norepinephrine
C) Production of antidiuretic hormone and corticosteroid hormones
D) Release of catecholamines

Accepted Answer

The answer of You are a student nurse being precepted...

Question 20

The nurse is caring for a client at risk for impending shock. The nurse is assessing the vital signs frequently. What systolic blood pressure(BP) value would indicate impending shock?
A) 122 mm Hg
B) 114 mm Hg
C) 91 mm Hg
D) 79 mm Hg

Accepted Answer

A systolic BP value of 90 mm Hg or below is typically considered hypotensive, and could indicate impending shock. Therefore, the closest value in the given options is 91 mm Hg.

Quiz 17: Caring for Clients in Shock

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?

As the nurse, you are clients' first line of defense in treating shock. When assessing a client for early signs of shock, what would you assess first?

The ICU nurse is required to closely monitor four clients diagnosed with shock. During the shift assessment, the nurse documents the following values for the clients. Which client is most stable?

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?

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?

Your client is in shock. You are to assess this client for inadequate oxygen delivery to the tissues. What is the first sign you will observe in the initial stages of shock?

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?

The nursing instructor is explaining the causes of shock. What are the causes of shock? Select all that apply.

Your client is in the ICU being treated for shock. The client's condition worsens as they become hypothermic and develop respiratory distress. What nursing intervention would help restore the body temperature to normal range?

You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock?

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?

What is the best reason for administering vasopressors after fluid therapy for a client in shock?

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

You are the nurse caring for a client with shock accompanied by lung congestion. How would you position this client?

The nursing instructor is discussing shock with her students. She describes the consequences of shock in the decompensation stage. What are these consequences? Select all that apply.

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?

You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the reabsorption and retention of fluid in the body?

The nurse is caring for a client at risk for impending shock. The nurse is assessing the vital signs frequently. What systolic blood pressure(BP) value would indicate impending shock?