Question 1

After a stroke, sensory-perceptual changes increase the client's risk for what?
A)Aspiration
B)Injury
C)Bleeding
D)Infection

Accepted Answer

A)Strokes often alter the ability to integrate, interpret, and attend to sensory data. The client may experience deficits in vision, hearing, equilibrium, taste, and smell. The ability to perceive vibration, pain, warmth, cold, and pressure may be impaired, as may proprioception (the body's sense of its position). The loss of these sensory abilities increases the risk for injury. Sensory-perceptual changes do not increase the risk for aspiration, bleeding, or infection, although stroke may cause these other complications.
B)Strokes often alter the ability to integrate, interpret, and attend to sensory data. The client may experience deficits in vision, hearing, equilibrium, taste, and smell. The ability to perceive vibration, pain, warmth, cold, and pressure may be impaired, as may proprioception (the body's sense of its position). The loss of these sensory abilities increases the risk for injury. Sensory-perceptual changes do not increase the risk for aspiration, bleeding, or infection, although stroke may cause these other complications.
C)Strokes often alter the ability to integrate, interpret, and attend to sensory data. The client may experience deficits in vision, hearing, equilibrium, taste, and smell. The ability to perceive vibration, pain, warmth, cold, and pressure may be impaired, as may proprioception (the body's sense of its position). The loss of these sensory abilities increases the risk for injury. Sensory-perceptual changes do not increase the risk for aspiration, bleeding, or infection, although stroke may cause these other complications.
D)Strokes often alter the ability to integrate, interpret, and attend to sensory data. The client may experience deficits in vision, hearing, equilibrium, taste, and smell. The ability to perceive vibration, pain, warmth, cold, and pressure may be impaired, as may proprioception (the body's sense of its position). The loss of these sensory abilities increases the risk for injury. Sensory-perceptual changes do not increase the risk for aspiration, bleeding, or infection, although stroke may cause these other complications.

Question 2

A client is receiving intravenous nitroprusside (Nipride)for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply.
A)Muscle spasms
B)Tachycardia
C)Confusion
D)Gastrointestinal bleeding
E)Disorientation

Accepted Answer

A)Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.
B)Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.
C)Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.
D)Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.
E)Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.

Question 3

The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session?
A)Improve muscle strength
B)Maintain cardiopulmonary function
C)Improve endurance
D)Maintain joint flexibility

Accepted Answer

A)The nurse should instruct the spouse that the exercises will help with joint flexibility. Passive range-of-motion exercises help maintain joint flexibility. Active range-of-motion exercises improve muscle strength, can help maintain cardiopulmonary functioning. And improve endurance.
B)The nurse should instruct the spouse that the exercises will help with joint flexibility. Passive range-of-motion exercises help maintain joint flexibility. Active range-of-motion exercises improve muscle strength, can help maintain cardiopulmonary functioning. And improve endurance.
C)The nurse should instruct the spouse that the exercises will help with joint flexibility. Passive range-of-motion exercises help maintain joint flexibility. Active range-of-motion exercises improve muscle strength, can help maintain cardiopulmonary functioning. And improve endurance.
D)The nurse should instruct the spouse that the exercises will help with joint flexibility. Passive range-of-motion exercises help maintain joint flexibility. Active range-of-motion exercises improve muscle strength, can help maintain cardiopulmonary functioning. And improve endurance.

Question 4

While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA)several months ago. The nurse should recognize that:
A)the client is at risk for an ischemic thrombotic stroke.
B)the client will have minimal symptoms should a stroke occur.
C)the client will not experience a stroke in the future.
D)the client is at high risk for a hemorrhagic stroke.

Accepted Answer

A)TIAs are often warning signs of an ischemic thrombotic stroke. There is no way to predict the symptoms the client will experience after a stroke. One or many TIAs may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a TIA.
B)TIAs are often warning signs of an ischemic thrombotic stroke. There is no way to predict the symptoms the client will experience after a stroke. One or many TIAs may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a TIA.
C)TIAs are often warning signs of an ischemic thrombotic stroke. There is no way to predict the symptoms the client will experience after a stroke. One or many TIAs may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a TIA.
D)TIAs are often warning signs of an ischemic thrombotic stroke. There is no way to predict the symptoms the client will experience after a stroke. One or many TIAs may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a TIA.

Question 5

What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis?
A)Intracerebral stroke
B)Subarachnoid stroke
C)Hemorrhagic stroke
D)Ischemic stroke

Accepted Answer

A)Strokes may be ischemic, occurring when the blood supply to a part of the brain is suddenly interrupted by a thrombus (blood clot), embolus (foreign matter traveling through the circulation), or stenosis (narrowing); or they may be hemorrhagic, occurring when a blood vessel breaks open and spills blood into spaces surrounding neurons. Intracerebral and subarachnoid are two types of hemorrhagic stroke.
B)Strokes may be ischemic, occurring when the blood supply to a part of the brain is suddenly interrupted by a thrombus (blood clot), embolus (foreign matter traveling through the circulation), or stenosis (narrowing); or they may be hemorrhagic, occurring when a blood vessel breaks open and spills blood into spaces surrounding neurons. Intracerebral and subarachnoid are two types of hemorrhagic stroke.
C)Strokes may be ischemic, occurring when the blood supply to a part of the brain is suddenly interrupted by a thrombus (blood clot), embolus (foreign matter traveling through the circulation), or stenosis (narrowing); or they may be hemorrhagic, occurring when a blood vessel breaks open and spills blood into spaces surrounding neurons. Intracerebral and subarachnoid are two types of hemorrhagic stroke.
D)Strokes may be ischemic, occurring when the blood supply to a part of the brain is suddenly interrupted by a thrombus (blood clot), embolus (foreign matter traveling through the circulation), or stenosis (narrowing); or they may be hemorrhagic, occurring when a blood vessel breaks open and spills blood into spaces surrounding neurons. Intracerebral and subarachnoid are two types of hemorrhagic stroke.

Question 6

The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client?
A)Deficient Fluid Volume
B)Ineffective Coping
C)Ineffective Airway Clearance
D)Decreased Cardiac Output

Accepted Answer

A)The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping. There is not enough information to determine whether the client has ineffective airway clearance.
B)The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping. There is not enough information to determine whether the client has ineffective airway clearance.
C)The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping. There is not enough information to determine whether the client has ineffective airway clearance.
D)The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping. There is not enough information to determine whether the client has ineffective airway clearance.

Question 7

A nurse working in the intensive care unit (ICU)is caring for a client in progressive hemorrhagic shock. What does the nurse understand about the physiology of progressive shock?
A)It involves a sustained decrease of 10 mmHg of the client's mean arterial pressure (MAP).
B)It involves a blood loss of 25%.
C)It involves a change from aerobic to anaerobic metabolism.
D)It involves a decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.

Accepted Answer

A)In decompensated or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35-50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
B)In decompensated or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35-50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
C)In decompensated or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35-50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
D)In decompensated or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35-50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.

Question 8

The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation?
A)Caucasians have an increased incidence of intracerebral hemorrhage.
B)African Americans have almost twice the number of first-ever strokes compared with Whites.
C)Asian Americans are more likely to die following a stroke than Whites.
D)The prevalence of hypertension among Hispanics is the highest in the world.

Accepted Answer

A)African Americans have almost twice the number of first-ever strokes compared with Caucasians and have the highest rate of hypertension compared to other races/ethnicities. Hispanics have an increased incidence of intracerebral hemorrhage. Individuals living in the Southeastern United States have the highest stroke mortality rate.
B)African Americans have almost twice the number of first-ever strokes compared with Caucasians and have the highest rate of hypertension compared to other races/ethnicities. Hispanics have an increased incidence of intracerebral hemorrhage. Individuals living in the Southeastern United States have the highest stroke mortality rate.
C)African Americans have almost twice the number of first-ever strokes compared with Caucasians and have the highest rate of hypertension compared to other races/ethnicities. Hispanics have an increased incidence of intracerebral hemorrhage. Individuals living in the Southeastern United States have the highest stroke mortality rate.
D)African Americans have almost twice the number of first-ever strokes compared with Caucasians and have the highest rate of hypertension compared to other races/ethnicities. Hispanics have an increased incidence of intracerebral hemorrhage. Individuals living in the Southeastern United States have the highest stroke mortality rate.

Question 9

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family?
A)Used to treat thrombotic and hemorrhagic strokes
B)Not associated with serious complications
C)Indicated if the stroke symptoms have occurred within the last 6 hours
D)Administered to break up existing clots and increase cerebral blood flow

Accepted Answer

A)Thrombolytic therapy using rt-PA is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment is only used with ischemic strokes. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage, causing extensive brain damage and disability. The treatment can be used if the symptoms have occurred within the last 3 hours.
B)Thrombolytic therapy using rt-PA is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment is only used with ischemic strokes. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage, causing extensive brain damage and disability. The treatment can be used if the symptoms have occurred within the last 3 hours.
C)Thrombolytic therapy using rt-PA is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment is only used with ischemic strokes. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage, causing extensive brain damage and disability. The treatment can be used if the symptoms have occurred within the last 3 hours.
D)Thrombolytic therapy using rt-PA is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment is only used with ischemic strokes. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage, causing extensive brain damage and disability. The treatment can be used if the symptoms have occurred within the last 3 hours.

Question 10

A client with a suspected transient ischemic attack (TIA)presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain?
A)Anterior cerebral artery
B)Vertebral artery
C)Left hemisphere of the brain
D)Right hemisphere of the brain

Accepted Answer

A)Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.
B)Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.
C)Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.
D)Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.

Question 11

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?
A)Encourage use of nonaffected arm to feed self, bathe, and dress.
B)Speak in normal conversational pattern and tones.
C)Provide complete care.
D)Talk loudly and distinctly.

Accepted Answer

A)To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the nonaffected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.
B)To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the nonaffected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.
C)To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the nonaffected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.
D)To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the nonaffected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.

Question 12

The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective?
A)"It's a protein that causes my kidneys to conserve fluid."
B)"It's a protein that pulls water into my blood vessels."
C)"It's a liquid that has electrolytes in it to pull water into my blood vessels."
D)"It's a super-concentrated salt solution that helps me conserve body fluid."

Accepted Answer

A)Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Albumin 5% does not act on the kidneys. Crystalloids are intravenous (IV)solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% is not a concentrated saline solution.
B)Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Albumin 5% does not act on the kidneys. Crystalloids are intravenous (IV)solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% is not a concentrated saline solution.
C)Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Albumin 5% does not act on the kidneys. Crystalloids are intravenous (IV)solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% is not a concentrated saline solution.
D)Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Albumin 5% does not act on the kidneys. Crystalloids are intravenous (IV)solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% is not a concentrated saline solution.

Question 13

The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?
A)Auscultate breath sounds for inspiratory stridor
B)Auscultate breath sounds for crackles
C)Auscultate breath sounds for hyperresonance
D)Auscultate for an absence of breath sounds in the lower lobes

Accepted Answer

A)Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. Stridor is auscultated with airway obstruction, not pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
B)Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. Stridor is auscultated with airway obstruction, not pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
C)Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. Stridor is auscultated with airway obstruction, not pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
D)Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. Stridor is auscultated with airway obstruction, not pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.

Question 14

The nurse is caring for a child who was burned in a house fire. The child has burns on 30% of his body, particularly his legs. The child suddenly goes into shock and needs CPR. What is the first step the nurse should take based on pediatric advanced life support (PALS)guidelines?
A)Begin ventilations
B)Begin chest compressions
C)Obtain a defibrillator
D)Establish vascular access

Accepted Answer

A)Based on PALS guidelines, the first step in providing life support to a child is to immediately begin chest compressions. This is the first step because no equipment is needed, so compressions can begin immediately. A second healthcare provider should begin ventilations with a bag and mask. A monitor and defibrillator should be obtained as the third step. Establishing vascular access should be the fourth step. The final step is calculating and preparing anticipated medications based on the child's weight.
B)Based on PALS guidelines, the first step in providing life support to a child is to immediately begin chest compressions. This is the first step because no equipment is needed, so compressions can begin immediately. A second healthcare provider should begin ventilations with a bag and mask. A monitor and defibrillator should be obtained as the third step. Establishing vascular access should be the fourth step. The final step is calculating and preparing anticipated medications based on the child's weight.
C)Based on PALS guidelines, the first step in providing life support to a child is to immediately begin chest compressions. This is the first step because no equipment is needed, so compressions can begin immediately. A second healthcare provider should begin ventilations with a bag and mask. A monitor and defibrillator should be obtained as the third step. Establishing vascular access should be the fourth step. The final step is calculating and preparing anticipated medications based on the child's weight.
D)Based on PALS guidelines, the first step in providing life support to a child is to immediately begin chest compressions. This is the first step because no equipment is needed, so compressions can begin immediately. A second healthcare provider should begin ventilations with a bag and mask. A monitor and defibrillator should be obtained as the third step. Establishing vascular access should be the fourth step. The final step is calculating and preparing anticipated medications based on the child's weight.

Question 15

A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client?
A)Cardiogenic shock
B)Hypovolemic shock
C)Neurogenic shock
D)Septic shock

Accepted Answer

A)Older adults who have a heart attack, especially those with a history of heart failure, diabetes, or hypertension, have an increased risk of cardiogenic shock. Therefore, the nurse should be monitoring the client for signs and symptoms of cardiogenic shock and be prepared to respond immediately to any warning signs of shock. Older adults are also at higher risk for progressing to other types of shock, but this client is at highest risk for cardiogenic shock.
B)Older adults who have a heart attack, especially those with a history of heart failure, diabetes, or hypertension, have an increased risk of cardiogenic shock. Therefore, the nurse should be monitoring the client for signs and symptoms of cardiogenic shock and be prepared to respond immediately to any warning signs of shock. Older adults are also at higher risk for progressing to other types of shock, but this client is at highest risk for cardiogenic shock.
C)Older adults who have a heart attack, especially those with a history of heart failure, diabetes, or hypertension, have an increased risk of cardiogenic shock. Therefore, the nurse should be monitoring the client for signs and symptoms of cardiogenic shock and be prepared to respond immediately to any warning signs of shock. Older adults are also at higher risk for progressing to other types of shock, but this client is at highest risk for cardiogenic shock.
D)Older adults who have a heart attack, especially those with a history of heart failure, diabetes, or hypertension, have an increased risk of cardiogenic shock. Therefore, the nurse should be monitoring the client for signs and symptoms of cardiogenic shock and be prepared to respond immediately to any warning signs of shock. Older adults are also at higher risk for progressing to other types of shock, but this client is at highest risk for cardiogenic shock.

Question 16

What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin?
A)Hypovolemic shock
B)Cardiogenic shock
C)Neurogenic shock
D)Septic shock

Accepted Answer

A)Early septic shock is characterized by normal to slightly decreased blood pressure; increased pulse and respirations; warm, flushed skin; and chills, among other symptoms. In hypovolemic and cardiogenic shock, the skin will typically be pale and cool rather than warm and flushed. In neurogenic shock, the pulse will be slow and bounding rather than rapid.
B)Early septic shock is characterized by normal to slightly decreased blood pressure; increased pulse and respirations; warm, flushed skin; and chills, among other symptoms. In hypovolemic and cardiogenic shock, the skin will typically be pale and cool rather than warm and flushed. In neurogenic shock, the pulse will be slow and bounding rather than rapid.
C)Early septic shock is characterized by normal to slightly decreased blood pressure; increased pulse and respirations; warm, flushed skin; and chills, among other symptoms. In hypovolemic and cardiogenic shock, the skin will typically be pale and cool rather than warm and flushed. In neurogenic shock, the pulse will be slow and bounding rather than rapid.
D)Early septic shock is characterized by normal to slightly decreased blood pressure; increased pulse and respirations; warm, flushed skin; and chills, among other symptoms. In hypovolemic and cardiogenic shock, the skin will typically be pale and cool rather than warm and flushed. In neurogenic shock, the pulse will be slow and bounding rather than rapid.

Question 17

A client with hemophilia is at increased risk for what type of shock?
A)Cardiogenic shock
B)Hemorrhagic shock
C)Anaphylactic shock
D)Distributive shock

Accepted Answer

A)Because clients with hemophilia have a decreased ability to form clots, they are at high risk for hemorrhagic shock. They are not at higher risk for cardiogenic, anaphylactic, or distributive shock unless they also have other underlying conditions, such as advanced cardiac disease or severe allergies.
B)Because clients with hemophilia have a decreased ability to form clots, they are at high risk for hemorrhagic shock. They are not at higher risk for cardiogenic, anaphylactic, or distributive shock unless they also have other underlying conditions, such as advanced cardiac disease or severe allergies.
C)Because clients with hemophilia have a decreased ability to form clots, they are at high risk for hemorrhagic shock. They are not at higher risk for cardiogenic, anaphylactic, or distributive shock unless they also have other underlying conditions, such as advanced cardiac disease or severe allergies.
D)Because clients with hemophilia have a decreased ability to form clots, they are at high risk for hemorrhagic shock. They are not at higher risk for cardiogenic, anaphylactic, or distributive shock unless they also have other underlying conditions, such as advanced cardiac disease or severe allergies.

Question 18

What is the purpose of using warm IV fluids to help resuscitate clients in shock?
A)To increase vasodilation
B)To prevent hypothermia
C)To prevent hyperthermia
D)To increase vasoconstriction

Accepted Answer

A)Using room-temperature fluids can cause hypothermia, which may hinder the effectiveness of treatment. Therefore, warmed IV fluids should be used to help resuscitate clients in shock. Use of warm IV fluids does not cause vasodilation or vasoconstriction, and it does not prevent hyperthermia.
B)Using room-temperature fluids can cause hypothermia, which may hinder the effectiveness of treatment. Therefore, warmed IV fluids should be used to help resuscitate clients in shock. Use of warm IV fluids does not cause vasodilation or vasoconstriction, and it does not prevent hyperthermia.
C)Using room-temperature fluids can cause hypothermia, which may hinder the effectiveness of treatment. Therefore, warmed IV fluids should be used to help resuscitate clients in shock. Use of warm IV fluids does not cause vasodilation or vasoconstriction, and it does not prevent hyperthermia.
D)Using room-temperature fluids can cause hypothermia, which may hinder the effectiveness of treatment. Therefore, warmed IV fluids should be used to help resuscitate clients in shock. Use of warm IV fluids does not cause vasodilation or vasoconstriction, and it does not prevent hyperthermia.

Question 19

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse?
A)"Be alert for sudden weakness or numbness."
B)"Know your family history."
C)"Keep a list of your medications."
D)"Call 911 if you notice a gradual onset of paralysis or confusion."

Accepted Answer

A)Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
B)Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
C)Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.
D)Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

Question 20

A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
A)Class I
B)Class II
C)Class III
D)Class IV

Accepted Answer

A)This client is in Class III (moderate)hemorrhagic shock, which is defined as a loss of 1,500-2,000mL, or 30-40% of blood volume.
B)This client is in Class III (moderate)hemorrhagic shock, which is defined as a loss of 1,500-2,000mL, or 30-40% of blood volume.
C)This client is in Class III (moderate)hemorrhagic shock, which is defined as a loss of 1,500-2,000mL, or 30-40% of blood volume.
D)This client is in Class III (moderate)hemorrhagic shock, which is defined as a loss of 1,500-2,000mL, or 30-40% of blood volume.

Quiz 16: Perfusion

After a stroke, sensory-perceptual changes increase the client's risk for what?

A client is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply.

The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session?

While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA) several months ago. The nurse should recognize that:

What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis?

The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client?

A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. What does the nurse understand about the physiology of progressive shock?

The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation?

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA) . Which information should the nurse include when performing medication teaching for the client's family?

A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain?

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?

The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective?

The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?

The nurse is caring for a child who was burned in a house fire. The child has burns on 30% of his body, particularly his legs. The child suddenly goes into shock and needs CPR. What is the first step the nurse should take based on pediatric advanced life support (PALS) guidelines?

A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client?

What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin?

A client with hemophilia is at increased risk for what type of shock?

What is the purpose of using warm IV fluids to help resuscitate clients in shock?

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse?

A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as: