Question 1

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department.The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock based on which of the following findings?

Accepted Answer

Neurogenic shock is characterized by a disruption of the sympathetic nervous system, resulting in vasodilation and decreased vascular resistance leading to hypotension and bradycardia. Therefore, bradycardia is the best choice to indicate possible neurogenic shock. Hypotension and cool, clammy skin are also common in shock, but they can be seen in other types of shock as well. A subnormal body temperature may be indicative of hypothermia, which may occur due to prolonged exposure to the environment rather than neurogenic shock.

Question 2

Which of the following is a patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia?

Accepted Answer

Normal mentation indicates adequate cerebral perfusion, which is a key outcome for a patient in shock with decreased cardiac output.

Question 3

A patient with hypovolemic shock has a urinary output of 15 mL/hour.What does the nurse understand is the compensatory physiological mechanism that leads to altered urinary output?

Accepted Answer

The release of aldosterone increases serum osmolarity, which in turn causes the release of antidiuretic hormone (ADH). This mechanism helps the body conserve water by reducing urine output, a compensatory response to hypovolemia.

Question 4

When caring for a patient in cardiogenic shock,the nurse evaluates the status of the patient,recognizing that which of the following is the goal of care?

Accepted Answer

The goal of care for a patient in cardiogenic shock is to decrease the workload on the heart and increase systemic perfusion. This can be achieved through interventions such as vasopressors, inotropes, and mechanical support to assist with cardiac output. Lowering the heart rate and controlling dysrhythmias may be necessary, but it is not the primary goal of care. Lowering blood pressure and respiratory rate may also be necessary in some cases, but it depends on the underlying cause of shock. Improving oxygen exchange and increasing urinary output are important goals of care, but they are not specific to cardiogenic shock.

Question 5

A patient stung by a bee develops severe respiratory distress and is in anaphylactic shock.Which medication will the nurse prepare to administer immediately?

Accepted Answer

Epinephrine (Adrenalin) is the medication of choice in the treatment of anaphylactic shock. It helps to constrict blood vessels, improve blood pressure, and stimulate the heart to improve cardiac output. It also works to relax the smooth muscles in the lungs, which helps to relieve respiratory distress. Crystalloid fluids may be given to support blood pressure, but they do not address the underlying anaphylaxis. Dexamethasone (Decadron) and Diphenhydramine (Benadryl) may be given as adjunct therapy, but they do not provide immediate relief from anaphylaxis.

Question 6

During the initial management of any patient in shock,the nurse knows that which of the following is an appropriate intervention?

Accepted Answer

The answer of During the initial management of any patient...

Question 7

Norepinephrine has been ordered for the patient in hypovolemic shock.Before administering the medication,the nurse ensures that which of the following has occurred?

Accepted Answer

Norepinephrine is a potent vasoconstrictor used to increase blood pressure in critically ill patients, such as those in hypovolemic shock. Before administering norepinephrine, it is crucial to ensure that the patient has received adequate fluid replacement to optimize blood volume and circulation. This helps prevent excessive vasoconstriction and potential ischemia that could occur if the drug is given to a patient with insufficient circulating volume.

Question 8

While caring for a seriously ill patient,the nurse determines that the patient may be in the compensatory stage of shock on observing which of the following findings?

Accepted Answer

Restlessness and apprehension are common signs of the compensatory stage of shock. Other signs that may be present include tachycardia, cool and clammy skin, and a narrowing pulse pressure. Cold, mottled extremities and a systolic BP less than 90 mm Hg are more indicative of the progressive or irreversible stages of shock.

Question 9

While evaluating the effects of treatment in a patient in shock,the nurse finds that the patient has orthostatic hypotension.This finding indicates a need for which of the following treatments?

Accepted Answer

Orthostatic hypotension, also known as postural hypotension, is a drop in blood pressure that occurs when a person stands up from a sitting or lying position. This can be caused by dehydration, which is common in patients with shock. Additional fluid replacement would help increase the patient's blood volume and possibly improve blood pressure. Antibiotics would not be indicated for orthostatic hypotension. Inotropic drugs, which stimulate the heart to beat more strongly, could be considered if the fluid replacement is not effective. Supplemental oxygen may be helpful for other conditions, but would not address the patient's orthostatic hypotension.

Question 10

Which type of shock does the nurse suspect with a patient who is short of breath and has wheezes,rhinitis,and stridor?

Accepted Answer

The symptoms of shortness of breath, wheezes, rhinitis, and stridor suggest an allergic reaction, which is indicative of anaphylactic shock.

Question 11

The nurse determines that the patient in shock has progressed beyond the compensated stage when laboratory tests reveal which of the following results?

Accepted Answer

Increased serum potassium levels indicate that the patient has progressed to the decompensated stage of shock, as the kidneys are no longer able to regulate potassium levels due to decreased perfusion. This can lead to potentially life-threatening cardiac arrhythmias. Increased blood glucose levels and serum sodium levels may be seen in the compensated and decompensated stages of shock, but they are not specific indicators of progression. Decreased serum calcium levels are not typically seen in shock.

Question 12

When caring for a patient in shock,the nurse notifies the physician of the patient's deteriorating status when the patient's arterial blood gas results include which of the following findings?

Accepted Answer

A low PaCO2 level indicates respiratory alkalosis, which can occur in shock. The low pH level and low PaCO2 level in option B indicate worsening respiratory alkalosis and possible hypoxemia, which would require prompt intervention and notification of the physician. Option A is indicative of respiratory alkalosis but with a high pH, which may not be as urgent as option B. Option C is indicative of respiratory alkalosis with metabolic alkalosis, and option D is within normal ranges for both pH and PaCO2.

Question 13

Which hemodynamic results would the nurse anticipate in a patient who is in cardiogenic shock?

Accepted Answer

In cardiogenic shock, the heart is unable to pump enough blood to meet the body's needs, leading to decreased cardiac output. The body will compensate by increasing heart rate, however, this may not be enough to maintain blood pressure. Therefore, the patient may present with an increased heart rate, decreased blood pressure, and decreased cardiac output.

Question 14

Which of the following nursing interventions prevents the development of shock?

Accepted Answer

Identifying situations in which patients are at risk for shock allows for early intervention and prevention measures to be implemented, reducing the likelihood of shock developing.

Question 15

What is an appropriate nursing intervention for a patient in shock with the nursing diagnosis of fear related to perceived threat of death?

Accepted Answer

Placing the patient's call bell where it can be easily reached allows the patient to feel a sense of control and empowerment, which can help to alleviate fear and anxiety. It also ensures that the patient can quickly and easily communicate with the healthcare team if they need assistance. While arranging for a member of the clergy to visit the patient or providing privacy with family may be appropriate interventions in some cases, they may not be effective in addressing the patient's fear in the immediate moment. Prescribing a sedative may be appropriate in some cases, but it should be used judiciously and with caution, as it can mask the patient's symptoms and make it more difficult to assess their condition.

Question 16

A patient in septic shock has not responded to fluid resuscitation,as evidenced by a decreasing BP and CO₂.The nurse anticipates the administration of which of the following medications?

Accepted Answer

The answer of A patient in septic shock has not...

Question 17

A patient has been admitted with a spinal cord injury.The nurse anticipates neurogenic shock with a spinal cord injury at which level of the spine?

Accepted Answer

Neurogenic shock is a potential complication of spinal cord injury that occurs when there is disruption of the sympathetic nervous system. This results in vasodilation and decreased systemic vascular resistance, leading to hypotension and bradycardia. Neurogenic shock is most commonly associated with injuries at the level of T6 or higher, but there is a higher risk of neurogenic shock with injuries at the level of T4 or above. Therefore, the best choice is A) T4.

Question 18

The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital.The caller states that they will be arriving in 1 minute.What will the nurse obtain in preparation for the patient's arrival?

Accepted Answer

The most important intervention in this scenario is to establish IV access. The recommended size for IV catheters in trauma patients is 14-gauge or larger. The nurse should obtain two 14-gauge IV catheters to be prepared for the patient's arrival. Options A and B are types of IV fluids that may be used in resuscitation, but the specific type and amount of IV fluid needed for this patient cannot be determined without a full assessment. Option D (a retention catheter) is not necessary for initial resuscitation and can be inserted after the patient has been stabilized.

Question 19

The nurse evaluates that fluid resuscitation for a patient in shock is effective on observing which of the following findings?

Accepted Answer

Urinary output of 1 mL/kg/hour is a sign of adequate perfusion to the kidneys and is considered an indicator of fluid resuscitation effectiveness in a patient in shock. Narrowing of pulse pressure, decreasing pulmonary artery occlusive pressure, and BP within the patient's normal range may be helpful in evaluating a patient's overall condition, but they are not specific indicators of the effectiveness of fluid resuscitation.

Question 20

A patient is treated in the emergency department for shock following an automobile accident.The nurse knows that shock is a clinical syndrome in which cellular dysfunction and organ failure occur primarily as a result of which of the following conditions?

Accepted Answer

Shock occurs primarily as a result of impaired tissue perfusion, which can result from a variety of causes including hypotension, loss of blood, severe infection, and other factors. Impaired tissue perfusion can lead to cellular dysfunction and organ failure, which are characteristic of the shock syndrome. While hypotension and loss of blood can contribute to impaired tissue perfusion, they are not the only causes and may not necessarily lead to shock. Severe infection can also contribute to impaired tissue perfusion, but not all infections result in shock.

Quiz 69: Nursing Management: Shock,systemic Inflammatory Response Syndrome,and Multiple-Organ Dysfunction Syndrome