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

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?

A) Bradycardia
B) Hypotension
C) Cool,clammy skin
D) A subnormal body temperature

Answer 1

Bradycardia

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?

A) Normal mentation
B) Increase in BP
C) Verbalization of reduced anxiety
D) Reduction in heart and respiratory rates

Answer 2

Normal mentation

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?

A) Release of aldosterone,which increases serum osmolarity,causing release of antidiuretic hormone (ADH)
B) Movement of interstitial fluid to the intravascular space,increasing renal blood flow
C) Activation of the sympathetic nervous system,causing vasodilation of the renal arteries
D) -Adrenergic receptor stimulation that causes increased CO₂ as a result of increased HR and myocardial contractility

Answer 3

Release of aldosterone,which increases serum osmolarity,causing release of antidiuretic hormone (ADH)

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?

A) To lower the HR and control dysrhythmias
B) To lower the BP and respiratory rate
C) To improve oxygen exchange and increase urinary output
D) To decrease cardiac workload and increase systemic perfusion

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?

A) Epinephrine (Adrenalin)
B) Crystalloid fluids
C) Dexamethasone (Decadron)
D) Diphenhydramine (Benadryl)

Question 6

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

A) Fluid resuscitation
B) Administration of vasopressors
C) Administration of inotropic agents
D) Administration of high-flow oxygen

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?

A) The patient's HR is less than 100 beats/min.
B) The patient's urinary output is within the normal range.
C) The patient has received adequate fluid replacement.
D) The patient is not receiving additional sympathomimetic drugs.

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?

A) Cold,mottled extremities
B) Restlessness and apprehension
C) An HR of 120 beats/min and cool,clammy skin
D) A systolic BP less than 90 mm Hg and a widening pulse pressure

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?

A) Additional fluid replacement
B) Administration of antibiotics
C) Administration of an inotropic drug
D) Administration of supplemental oxygen

Question 10

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

A) Cardiogenic shock
B) Neurogenic shock
C) Anaphylactic shock
D) Septic 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?

A) Increased blood glucose levels
B) Increased serum sodium levels
C) Decreased serum calcium levels
D) Increased serum potassium levels

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?

A) pH 7.48,partial pressure of arterial carbon dioxide (PaCO₂)33 mm Hg
B) pH 7.33,PaCO₂ 30 mm Hg
C) pH 7.50,PaCO₂ 50 mm Hg
D) pH 7.38,PaCO₂ 45 mm Hg

Question 13

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

A) Increased heart rate (HR),blood pressure (BP),and cardiac output (CO₂)
B) Increased HR,decreased BP and CO₂
C) Decreased HR,BP,and CO₂
D) Decreased HR,increased BP and CO₂

Question 14

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

A) Routine checking of stools for occult blood
B) Keeping patients warm to prevent chilling or shivering
C) Identifying situations in which patients are at risk for shock
D) Frequent monitoring of patient status to detect compensatory changes

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?

A) Arrange for a member of the clergy to visit the patient.
B) Ask the physician to prescribe a sedative for the patient.
C) Provide the patient with as much privacy with the family as possible.
D) Place the patient's call bell where it can be easily reached.

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?

A) Nitroglycerine (Tridil)
B) Dobutamine
C) Norepinephrine (Levophed)
D) Sodium nitroprusside (Nipride)

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?

A) T4
B) T6
C) T8
D) L2

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?

A) A litre of lactated Ringer's solution
B) 500 mL of 5% albumin
C) Two 14-gauge IV catheters
D) A retention catheter

Question 19

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

A) Urinary output is 1 mL/kg/hour.
B) Pulse pressure becomes narrower.
C) Pulmonary artery occlusive pressure decreases.
D) BP is within the patient's normal range.

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?

A) Hypotension
B) Loss of blood
C) Severe infection
D) Impaired tissue perfusion

Question 21

When caring for the patient with cardiogenic shock and possible multiple-organ dysfunction syndrome (MODS),what information obtained by the nurse will help confirm the diagnosis of MODS?

A) The patient has crackles throughout both lung fields.
B) The patient complains of crushing chest pain at a level of 8 on a 10-point scale.
C) The patient has an elevated ammonia level and confusion.
D) The patient has cool extremities and weak pedal pulses.

Question 22

To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS,what should the nurse assess?

A) Stool guaiac and bowel sounds
B) Lung sounds and oxygenation status
C) Serum creatinine and urinary output
D) Serum bilirubin levels and skin colour

Question 23

When caring for a patient who has just been admitted with septic shock,which of these assessment data will be of greatest concern to the nurse?

A) BP 88/56 mm Hg
B) Apical pulse 110 beats/min
C) Urinary output 15 mL for 2 hours
D) Arterial oxygen saturation 90%

Question 24

Which hemodynamic results would the nurse expect to assess in a patient who is in neurogenic shock?

A) Increased HR,decreased BP and pulse pressure
B) Increased HR,BP,and pulse pressure
C) Decreased HR,increased BP and pulse pressure
D) Decreased HR,BP,and pulse pressure