Question 1

A patient in shock has a falling blood pressure.What should the nurse realize occurs as the sympathetic nervous system responds to falling blood pressure? (Select all that apply.)

Accepted Answer

F.As a compensatory mechanism (fight or flight),blood is shunted away from the skin,kidneys,and intestines to supply the major organs.A.Blood glucose levels increase for energy.B.Sodium and water are retained to ensure adequate fluid volume.E.Epinephrine is released from the adrenal medulla to stimulate increased cardiac output.C.D.Vasoconstriction occurs,and the goal is to increase oxygen delivered to the tissues.

Question 2

A patient is admitted for care because of heat stroke.Why should the nurse include interventions to prevent the onset of shock?

Accepted Answer

Heat exhaustion or heatstroke can also cause hypovolemic shock by excessive water loss through sweating.A.Excessive dilation of veins and arteries can lead to distributive shock.B.There is no evidence to support that the patient is unable to tolerate oral fluids.C.Parasympathetic stimulation causing blood to pool in the extremities is associated with neurogenic shock.

Question 3

The spouse of a patient in neurogenic shock asks what is happening to the patient.How should the nurse response to the spouse?

Accepted Answer

Neurogenic shock is a form of distributive shock in which massive vasodilation of the peripheral circulation occurs,causing hypotension.A.B.C.Neurogenic shock is not caused by an allergic reaction,drop in circulating blood volume,or heart failure.

Question 4

The nurse is assisting in the planning of care for a patient in shock.Which nursing diagnoses should the nurse recommend be included in the patient's plan of care?

Accepted Answer

Shock is defined as inadequate tissue perfusion so the nursing diagnosis of inadequate tissue perfusion is appropriate for the nurse to recommend.A.Shock does not necessarily lead to hopelessness.B.The patient in shock is not necessarily at risk for aspiration.C.Excess fluid volume would be appropriate for the patient experiencing cardiogenic shock.

Question 5

The nurse is assisting in the care of a patient with early signs and symptoms of shock.Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.)

Accepted Answer

Complete blood count,chest x-ray,blood typing and crossmatch,arterial blood gases,and urinalysis are diagnostic tests done in the assessment of shock.E.EEG would not be done.

Question 6

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 should indicate to the nurse that the patient is in which stage of shock?

Accepted Answer

Symptoms of decompensated shock include slowing heart rate,systolic blood pressure less than 60 mm Hg,decreasing temperature,decreasing respiration rate,and almost no urine output as compensation mechanisms have failed and death is imminent.A.C.D.These manifestations do not indicate that the patient is in mild,moderate,or compensated shock.

Question 7

A patient in shock is diagnosed with metabolic acidosis.What should the nurse realize as being the mechanism behind the development of this acid-base imbalance?

Accepted Answer

Anaerobic metabolism results in the production of lactic acid as an unwanted by-product.Unless the lactic acid can be circulated to the liver and removed from the bloodstream,the blood will become increasingly acidic.A.Metabolic acidosis will not develop in the presence of aerobic metabolism.C.Decreased anaerobic metabolism will not cause metabolic acidosis to develop.D.The release of cortisol and glucagon ensures the body tissues receive fuel because of the shock.

Question 8

A patient in shock is found unresponsive.The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes?

Accepted Answer

If the brain is deprived of circulation for more than 4 minutes,brain cells die from a lack of oxygen and glucose.As a result,prolonged shock can result in brain death.A.B.Brain cells do not begin to die until 4 minutes have passed without oxygen and glucose.D.Brain cells are dying if deprived of oxygen and glucose for 8 minutes.

Question 9

The nurse is monitoring a patient being for septic shock.Which findings indicate that the patient is improving? (Select all that apply.)

Accepted Answer

Oxygen saturation of 94%,pulse of 75 beats/minute,and blood pressure of 110/90 mm Hg all indicate that the patient is improving.F.Urine output should be 30 mL/hr to be normal.D.Normal temperature is 98.6°F (37°C).B.pH below 7.35 is abnormal and indicates ongoing acidosis related to shock.

Question 10

The nurse is caring for an 85-year-old patient with septic shock.What should the nurse keep in mind when repositioning this patient?

Accepted Answer

For the geriatric patient,positions should be changed slowly.Age-related losses of cardiovascular reflexes can result in hypotension.B.C.The oxygen and IV flow rates cannot be changed without a health care provider's order.D.Trendelenburg position is not indicated for this health problem.

Question 11

Patients are being treated in the intensive care unit for anaphylactic,septic,and neurogenic shock.For which type of shock should the nurse plan to provide care?

Accepted Answer

Subcategories of distributive shock include anaphylactic,septic,and neurogenic shock.A.Obstructive shock is caused by a blockage of blood flow in the cardiovascular circuit outside the heart.C.Cardiogenic shock is caused by heart pump failure.D.Hypovolemic shock is caused by a decrease in the circulating blood volume.

Question 12

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 type of shock should the nurse suspect is occurring in this patient?

Accepted Answer

During the early,or warm,phase of septic shock,blood pressure,urine output,and neck vein size may be normal,but the skin is warm and flushed.Fever is present in the majority of patients,although some may have a subnormal temperature.D.Septic shock progresses to a second phase with signs and symptoms similar to hypovolemic shock: hypotension; oliguria; tachycardia; tachypnea; flat jugular and peripheral veins; and cold,clammy skin.Body temperature may be normal or subnormal.B.C.There is no reason to suspect that this patient is experiencing neurogenic or cardiogenic shock.

Question 13

The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock.What should the nurse do if the patient's urine output drops to 15 mL for one hour of monitoring?

Accepted Answer

The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage.Cells in the kidneys die when there is a lack of oxygen and nutrients.If there is widespread damage to the kidneys,complete renal failure is likely.A.The nurse needs to do more than document the findings.B.The urinary catheter does not need to be flushed.C.Clamping the catheter for 30 minutes is not going to improve the patient's urine output.

Question 14

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 charge nurse can notify the physician so orders can be received to aid the critically ill patient.A.The supine position would hinder breathing.D.Increased fluids could overwhelm the heart.C.Urine specific gravity is used to determine fluid volume status and is not needed for this patient.

Question 15

The nurse is receiving report on patients assigned for the next shift.Which patient should the nurse observe first?

Accepted Answer

The patient may be having an allergic reaction and requires immediate attention to intervene as anaphylactic shock may occur.A.B.D.There are no abnormalities occurring that require immediate intervention.

Question 16

After collecting data,the nurse suspects that a patient is experiencing cardiogenic shock.Which finding supports this nurse's suspicion?

Accepted Answer

The presence of pulmonary edema is what differentiates cardiogenic shock from other forms of shock.A.B.C.Oliguria,tachypnea,and bronchospasm are manifestations associated with other forms of shock.

Question 17

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

Accepted Answer

Septic shock can develop from invasive procedures and devices.Indwelling urinary catheters can precipitate the development of septic shock.B.C.D.Cardiogenic,anaphylactic,and hypovolemic shock are not associated with the use of urinary catheters.

Question 18

A patient who is taking atenolol (Tenormin)is experiencing shock.Which symptom of shock should the nurse expected to be absent in this patient?

Accepted Answer

Tachycardia will not be present as expected with sympathetic nervous system activation.Beta blockers block the response of the sympathetic nervous system,which is activated in shock.B.The sympathetic nervous system is activated in shock so respirations increase.C.Blood pressure drops in shock.D.Prolonged capillary refill is expected in shock due to decreased blood pressure and vasoconstriction from sympathetic nervous system response.

Question 19

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

Accepted Answer

Normal blood pressure,tachycardia,and rapid respirations occur in mild shock due to compensatory mechanisms.B.C.D.As shock progresses and compensatory mechanisms begin to fail,vital signs decrease.

Question 20

The nurse discovers that a patient recovering from surgery is hemorrhaging from the incisional site.What action should the nurse take?

Accepted Answer

The first priority is to control the bleeding with direct pressure.A.B.C.The other options may be considered but are not the first priority.

Quiz 9: Nursing Care of Patients in Shock