Question 1

As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms indicate to the nurse that the patient is in which stage of shock?

Accepted Answer

The signs and symptoms mentioned in the scenario indicate that the patient is in the severe stage of shock. This is characterized by significant hypotension (systolic blood pressure less than 60 mm Hg), worsening tachycardia or even bradycardia (slowing heart rate), decreased body temperature, respiratory distress (decreasing respiration rate), and low urine output. Immediate intervention is necessary in this stage to prevent irreversible organ damage and even death.

Question 2

The nurse is caring for a patient in shock and explains procedures and treatment to the patient. The nurse provides these explanations for which of the following reasons? (Select all that apply.?

Accepted Answer

The nurse is providing explanation to the patient to provide support and decrease anxiety, which are both important aspects in the care of a patient in shock. The explanations may also help to prevent future shock episodes by promoting a better understanding of the patient's condition and the treatments used to manage it. However, reducing the signs of shock is not the primary reason for providing explanations in this case.

Question 3

The nurse would recognize cardiogenic shock from other types of shock by the data collection findings for which of the following?

Accepted Answer

Pulmonary edema is a hallmark finding in cardiogenic shock. It is caused by increased pressure in the pulmonary veins and capillaries as a result of decreased cardiac output. Bronchospasm, oliguria, and tachypnea are not specific to cardiogenic shock and can be present in other types of shock as well.

Question 4

A patient with a history of a myocardial infarction has chest pain. The patient's skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take?

Accepted Answer

The patient is presenting with symptoms of a possible acute coronary syndrome, and the nurse should notify the registered nurse or physician immediately to initiate appropriate interventions. Placing the patient supine and infusing normal saline are not the priority interventions in this scenario. Checking urine specific gravity is not relevant to the patient's current presentation.

Question 5

Which one of the following nursing diagnoses would be most appropriate for the nurse to recommend be included in the patient's plan of care for a patient in shock?

Accepted Answer

In shock, the body is unable to adequately perfuse tissues with oxygen and nutrients. Therefore, "Inadequate tissue perfusion" is the most appropriate nursing diagnosis to address this issue and guide the development of a plan of care. "Excess fluid volume" may be a concern in some cases, but it is not as directly related to shock as inadequate tissue perfusion. "Hopelessness" and "Risk for aspiration" may be valid nursing diagnoses in certain situations, but they are not specifically related to shock.

Question 6

The nurse is contributing to a staff education program about complications associated with urinary catheters. Which of the following types of shock should the nurse recommend be included in the presentation?

Accepted Answer

Septic shock can occur as a complication of urinary catheterization due to the risk of bacterial infection. The other types of shock listed (anaphylactic, cardiogenic, hypovolemic) are not typically associated with urinary catheterization.

Question 7

Which of the following signs and symptoms would the nurse expect to see for a patient going into anaphylactic shock? (Select all that apply.?

Accepted Answer

Urticaria (hives), laryngeal edema (swelling of the throat), and bronchospasm (constriction of the airways) are all common signs and symptoms of anaphylactic shock. Polyuria (increased urination) is not typically associated with anaphylaxis.

Question 8

Which of the following occurs as the body's sympathetic nervous system responds to falling blood pressure? (Select all that apply.?

Accepted Answer

The sympathetic nervous system responds to falling blood pressure by shunting blood away from less vital organs to maintain blood flow to critical organs (A), increasing blood glucose levels for energy (C), retaining sodium and water to increase blood volume (D), and releasing epinephrine from the adrenal medulla to enhance the body's overall response to stress, including increasing heart rate and blood pressure (F).

Question 9

The nurse is monitoring a patient who has been treated for several days for septic shock after surgery. Which of the following findings indicate that the patient is improving? (Select all that apply.?

Accepted Answer

An SpO2 of 94% indicates adequate oxygenation, a blood pressure of 110/90 mm Hg suggests improved hemodynamic stability, and a pulse of 75 beats/minute is within normal range, all of which are signs of improvement in a patient recovering from septic shock.

Question 10

The nurse receives an assignment of patients. Which of the following patients should the nurse observe first?

Accepted Answer

The patient with cellulitis receiving the first dose of intravenous antibiotics and reporting a feeling of tightness in the throat could be experiencing an allergic reaction to the medication and requires immediate assessment and intervention. The other patients can be assessed and treated in a timely manner but are not experiencing acute, life-threatening symptoms.

Question 11

The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which of these vital sign changes should the nurse report as indicative of early shock?

Accepted Answer

Early signs of shock include normal to slightly decreased blood pressure, tachycardia (rapid heart rate), and rapid respirations as the body attempts to compensate for decreased blood volume by increasing heart rate and respiratory rate to maintain oxygen delivery to tissues.

Question 12

The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which of the following diagnostic tests would the nurse expect? (Select all that apply.?

Accepted Answer

In early shock, diagnostic tests like a complete blood count (A) can help assess for infection or anemia, a chest x-ray (B) can evaluate respiratory status, blood type and crossmatch (D) is crucial for potential transfusions, arterial blood gas (E) assesses oxygenation and acid-base balance, and urinalysis (F) can provide information on kidney function and hydration status. An EEG (C) is not typically relevant for shock assessment.

Question 13

A patient is transferred to the intensive care unit in neurogenic shock. The patient's wife asks what is happening. Which of these responses should the nurse give?

Accepted Answer

Neurogenic shock is a type of distributive shock in which there is a sudden loss of sympathetic tone causing massive vasodilation and decreased vascular resistance, leading to hypotension and decreased tissue perfusion. The correct response would be to explain to the patient's wife that her husband's blood vessels have dilated, causing a drop in blood pressure.

Question 14

The metabolic acidosis of shock is caused by which of these mechanisms?

Accepted Answer

Metabolic acidosis in shock is caused by excessive anaerobic metabolism, leading to an accumulation of lactic acid. Reduced tissue perfusion, which occurs in shock, leads to decreased oxygen supply to the tissues and increased reliance on anaerobic metabolism. This results in an increase in lactate production, leading to metabolic acidosis.

Question 15

The nurse is monitoring a patient who has been in prolonged shock. For which of the following serious complications would the nurse observe to report? (Select all that apply.?

Accepted Answer

The answer of The nurse is monitoring a patient who...

Question 16

A patient who had surgery 3 days ago has a temperature of 98°F (36.6°C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which of these types of shock does the nurse recognize is likely occurring?

Accepted Answer

Septic shock is a type of distributive shock that is caused by a bacterial infection. It is characterized by hypotension, tachycardia, and tachypnea. The patient's temperature is also elevated, which is a sign of infection.

Question 17

The nurse would recognize anaphylactic, septic, and neurogenic shock as examples of what type of shock?

Accepted Answer

Anaphylactic, septic, and neurogenic shock are all examples of distributive shock, which is characterized by vasodilation and decreased systemic vascular resistance, leading to poor tissue perfusion.

Question 18

The nurse discovers a patient after surgery who is hemorrhaging from the incisional site. What is the most important action the nurse should take?

Accepted Answer

Applying pressure to the bleeding site is the most important action to take as it helps control the bleeding and prevents further blood loss, which can become life-threatening. Offering oral fluids, warming the patient or relieving their apprehension can wait until the bleeding is under control.

Question 19

The nurse is caring for a patient experiencing shock who is taking Atenolol (Tenormin). Which of the following symptoms of shock would be expected to be present in this patient? (Select all that apply.?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 20

The nurse is monitoring hourly urine output on a patient who has a urinary catheter inserted. The nurse understands that the kidneys can tolerate reduced blood flow for about ________________hour(s) before permanent damage occurs, which can be exhibited by reduced urine output that would need to be reported.

Accepted Answer

The answer of The nurse is monitoring hourly urine output...

Quiz 9: Nursing Care of Patients in Shock