Deck 17: Caring for Clients in Shock

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.

Answer 1

It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.

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

Answer 2

Vital signs, skin color, and temperature

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

Answer 3

Client C: Heart rate 115 beats per minute, systolic BP 129 mm Hg, urine output 60 mL/hour

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.

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

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

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

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.

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.

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.

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.

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

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

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

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

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

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

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

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

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

Question 21

You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?

A) Decreases peripheral blood flow
B) Increases catacholamine secretion
C) Increases the production of antidiuretic hormone
D) Restores blood pressure

Question 22

You are the Emergency Department nurse caring for a client admitted with hypovolemic shock. IV fluids have been ordered. What ratio is usually ordered for replacement fluids?

A) 1:1
B) 2:1
C) 3:1
D) 4:1

Question 23

You are caring for a client in the compensation stage of shock. You know that in this stage of shock epinephrine and norepinephrine are released into the circulation. What positive effect does this have on your client?

A) Increases myocardial contractility
B) Decreases blood return to the heart
C) Decreases carbon dioxide exchange
D) Contracts bronchioles

Question 24

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?

A) Hormone antagonist drugs
B) Antimetabolite drugs
C) Adrenergic drugs
D) Anticholinergic drugs

Question 25

At what point in shock does metabolic acidosis occur?

A) Compensation
B) Irreversible
C) Early
D) Decompensation