Question 1

The emergency department nurse is assessing a client in shock. The nurse understands that shock can be caused by which conditions? Select all that apply.

Accepted Answer

B, C, D, E

Question 2

The critical care nurse is assessing a client for clinical signs of shock. Which assessment finding does the nurse understand to be a clinical sign of shock?

Accepted Answer

Cold, clammy skin is a common clinical sign of shock due to decreased blood flow to the skin as the body prioritizes vital organs.

Question 3

The nurse is providing discharge instructions to a client hospitalized with a bacterial infection. Which statement will the nurse include in the education?

Accepted Answer

An unresolved bacterial infection can lead to septic shock, which is a severe and potentially life-threatening condition caused by the body's response to infection.

Question 4

The nurse is providing care to a client with multiple organ dysfunction syndrome (MODS). What does the nurse understand is occurring in the body's cells as a result?

Accepted Answer

In multiple organ dysfunction syndrome (MODS), there is inadequate oxygen delivery to tissues, leading to a shift from aerobic to anaerobic metabolism, which results in increased lactic acid production.

Question 5

The nurse is caring for a client with early shock. The nurse understands that which mechanism in the body is maintaining the client's blood flow?

Accepted Answer

The renin-angiotensin-aldosterone system is activated in response to poor perfusion, helping to maintain blood flow by increasing blood volume and vasoconstriction.

Question 6

The nurse is caring for a client presenting with confusion, angina, and muscular pain. The nurse understands that these findings are consistent with which stage of shock?

Accepted Answer

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

Question 7

The emergency department nurse receives a call about an incoming client with hypovolemic shock. The nurse understands that which conditions can result in hypovolemic shock? Select all that apply.

Accepted Answer

The answer of The emergency department nurse receives a call...

Question 8

The critical care nurse is preparing to admit a client with suspected hypovolemic shock to the intensive care unit. Which laboratory tests does the nurse anticipate to be included in the client's plan of care? Select all that apply.

Accepted Answer

The answer of The critical care nurse is preparing to...

Question 9

The nurse is reviewing the plan of care for a client with hypovolemic shock. Which objectives does the nurse recognize are relevant for this client? Select all that apply.

Accepted Answer

In hypovolemic shock, the primary objectives are to prevent further fluid loss, replace lost fluids to restore blood volume, and maximize oxygen delivery to tissues. Reducing body temperature and blood pressure are not relevant objectives in this context.

Question 10

The nurse is caring for a client with an acute myocardial infarction. The nurse understands that this condition results in cardiogenic shock by which mechanism?

Accepted Answer

Cardiogenic shock in the context of an acute myocardial infarction is primarily due to increased left ventricular pressure, which results from the heart's inability to pump effectively, leading to decreased cardiac output and inadequate tissue perfusion.

Question 11

The nurse is providing education to a client's family about cardiogenic shock. Which statement should be included in the education?

Accepted Answer

In cardiogenic shock, the body attempts to compensate by shunting blood to vital organs to maintain their function, despite the heart's reduced ability to pump effectively.

Question 12

The nurse is preparing to administer a client's medications. Which medications does the nurse recognize are used to treat the client's diagnosis of cardiogenic shock? Select all that apply.

Accepted Answer

Nitroglycerine (C) is used to reduce preload and afterload, improving cardiac output. Diuretics (D) help reduce fluid overload and decrease cardiac workload. Thrombolytic therapy (E) is used to dissolve clots that may be contributing to the shock.

Question 13

The nurse is preparing to admit a client diagnosed with anaphylactic shock. The nurse understands that anaphylactic shock can have which triggers?

Accepted Answer

Anaphylactic shock can be triggered by drugs, foods, and proteins, which can cause severe allergic reactions. Hyperthermia and inactivity are not typical triggers for anaphylactic shock.

Question 14

While assessing a client, the nurse notes stridor, tachycardia, edema, and hives. The nurse understands that these findings are consistent with which type of shock?

Accepted Answer

These symptoms are indicative of anaphylactic shock, which is a severe allergic reaction characterized by stridor (due to airway swelling), tachycardia, edema, and hives.

Question 15

The nurse is reviewing medications for a client with anaphylactic shock. Which medication would the nurse anticipate to be included in the client's plan of care? Select all that apply.

Accepted Answer

Epinephrine is the first-line treatment for anaphylactic shock as it helps to quickly reverse the symptoms. Beta agonists may be used to help with bronchospasm. Diphenhydramine, an antihistamine, can be used to manage allergic reactions. Lorazepam and Heparin are not typically used in the treatment of anaphylactic shock.

Question 16

The nurse is providing education about anaphylaxis to a parent at a well-child visit. Which agents does the nurse include when reviewing common causes of anaphylaxis in children? Select all that apply.

Accepted Answer

Nuts and bee stings are common allergens that can cause anaphylaxis in children. Lead-based paint, low grade plastics, and pool chemicals are not typical causes of anaphylaxis.

Question 17

The nurse is assisting with a client undergoing a sequential organ failure assessment (SOFA). Which systems will the nurse anticipate being included in the assessment? Select all that apply.

Accepted Answer

The SOFA score assesses the function of six organ systems: respiratory, cardiovascular, hepatic, coagulation, renal, and neurological.

Question 18

The nurse is reviewing orders for a client with a diagnosis of septic shock. Which order will the nurse verify with the health care provider before proceeding?

Accepted Answer

Intravenous furosemide is a diuretic and may not be appropriate in septic shock as it can lead to further hypotension and decreased perfusion. The nurse should verify this order with the healthcare provider.

Question 19

The nurse is providing education to a client about how the body responds to pulmonary emboli. Which statement will the nurse include in the teaching?

Accepted Answer

Pulmonary embolism can lead to obstructive shock due to blockage in the pulmonary circulation, which impedes blood flow and affects cardiac output.

Question 20

The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). Which statement about this condition does the nurse know to be true?

Accepted Answer

MODS can present with variable clinical presentations because it affects multiple organ systems, and the manifestations can vary depending on which organs are involved and the severity of the dysfunction.

Quiz 28: Shock and Multiple Organ Dysfunction Syndrome