Question 1

One of the most important assessments that the nurse makes is to check urine output.The value that objectively validates minimal acceptable renal perfusion for the average-size person is:

Accepted Answer

When the kidneys produce at least 0.5 ml/kg/hr of urine,the indication is that the vital organs are also being perfused.

Question 2

A nurse explains to a family member the pathophysiologic characteristic of vasogenic shock,which is:

Accepted Answer

Blood pooling from dilated vessels drops the blood pressure without loss of circulating volume.

Question 3

The licensed practical/vocational nurse (LPN/LVN),assisting in developing a nursing care plan for a patient in shock,would include the nursing diagnosis of:

Accepted Answer

Decreased amount of blood is ejected from the heart because of a decreased volume of fluid in the intravascular compartment.

Question 4

Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock,shock itself results from failure of which system?

Accepted Answer

When the heart fails as a pump,the lack of tissue perfusion follows and deprives all the body's cells of oxygen and the removal of wastes.

Question 5

The nurse assessing a patient who is in shock is aware that one common sign that the nurse will find,regardless of the cause of the shock,is:

Accepted Answer

Venous blood pools in the extremities of the fingers as a result of the lack of adequate perfusion of tissues,which makes the skin cool and moist from a lack of oxygen and waste exchanges.

Question 6

The nurse is administering dopamine to the patient to treat the shock syndrome.The expected action of this drug is as a(n):

Accepted Answer

Digitalis (Lanoxin)improves the force of the heart to eject blood without increasing the rate of the action.

Question 7

The nurse explains that the intraaortic balloon pump (IABP)assists the patient who is in cardiogenic shock to increase cardiac output by:

Accepted Answer

The IABP inflates during diastole (relaxation)phase and deflates during the systole (constriction)phase,which improves cardiac output.

Question 8

Because of the falling blood pressure and impaired blood circulation during the refractory stage of shock,the nurse expects that the respirations will be:

Accepted Answer

During the refractory stage of shock as the body systems are failing,the respirations become slow,shallow,and irregular.Death is imminent at this stage.

Question 9

The nurse reviews the four types of shock,which are:

Accepted Answer

The four large categories of shock are hypovolemic (low-circulating volume),cardiogenic (low-cardiac output),obstructive (occluded vascular pathway),and vasogenic (massive vasodilation).

Question 10

The nurse explains that the use of medical antishock trousers (MAST)garment compress the legs and abdomen to:

Accepted Answer

MAST trousers compress the vessels in the legs and abdomen to increase both blood pressure and cardiac output.

Question 11

The nurse caring for a patient who has a cervical spine injury immediately documents and reports the assessment of progressive hypotension as a sign of probable:

Accepted Answer

Gradually decreasing blood pressure in a person with a spinal injury is an indicator of neurogenic shock,related to the parasympathetic stimulation,which causes generalized vasodilation.

Question 12

While shopping in the mall,the nurse sees a lady suddenly fall to the floor.On immediate assessment,the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR).The immediate actions by the nurse are to:

Accepted Answer

Shock treatment requires expert medical implementation.However,the nurse may provide first-line support until such help arrives.Circulatory collapse has to be monitored first; pulse,respiration,and mental status should be assessed to evaluate whether oxygen is reaching the brain.

Question 13

The position that would enhance cerebral blood flow to counteract the symptoms of compensatory shock is:

Accepted Answer

The Trendelenburg position,with the patient's head down,allows gravity to pull blood to the cerebrum.All other positions are ineffective for improving cerebral perfusion.

Question 14

The stages of shock proceed in a definite sequence.What is the correct order?

Accepted Answer

Understanding the sequence of the progression of shock allows the medical team to plan and implement the correct steps to reverse it.

Question 15

When speaking to the family of a 65-year-old Hispanic woman,the nurse will address most conversation to the:

Accepted Answer

Many older Hispanic families recognize the older men in the family,the father or husband,as the decision makers.

Question 16

Nursing interventions to help the patient cope with decreased cardiac output include which one of the following?

Accepted Answer

Care should be designed to reduce metabolic demands on the failing heart.Shivering and physical activity increase the demands; analgesics may reduce output more.

Question 17

The nurse is administering heparin,subcutaneous twice daily,for a patient in cardiogenic shock.The expected action of this drug is as a(n):

Accepted Answer

Cardiogenic shock may produce clots because of blood stasis,and the heparin will delay clot formation.

Question 18

In treating a person outside of a medical facility,the nurse knows that immediate circulatory support for the vital organs must begin as quickly as possible because,without oxygen,the brain cells will begin to die in how many minutes?

Accepted Answer

Brain cells must have oxygen to live; they are very sensitive to lack of oxygen and begin to die in 4 minutes.

Question 19

The nurse assessing a patient in the progressive stage of shock would expect to find:

Accepted Answer

When the heart fails as a pump,the pulse is weak,the respirations increase in an effort to decrease the carbon dioxide level,and,with less volume being pumped,the blood pressure falls.

Question 20

The cool,damp skin of patients in compensatory shock is caused by:

Accepted Answer

When overall blood volume is reduced in shock,the remaining blood volume is shunted to vital organs.

Quiz 19: Shock