39

Chapter 39: Care of Patients with ShockTest Bank

MULTIPLE CHOICE

1.The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, The doctor said she has shock. What is that? What is the nurses best response?a.Shock occurs when oxygen to the bodys tissues and organs is impaired.b.Shock is a serious condition, but it is not a life-threatening emergency.c.Shock progresses slowly and can be stopped by the bodys normal compensation.d.Shock is a condition that affects only specific body organs like the kidneys.

ANS:AAny problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the whole-body response, affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death.

DIF:Cognitive Level: Knowledge/RememberingREF:p. 809TOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Implementation)

2.The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock?a.Severe head injury from a motor vehicle accidentb.Diabetes insipidus from polycystic kidney diseasec.Ischemic cardiomyopathy from severe coronary artery diseased.Vomiting of blood from a gastrointestinal ulcer

ANS:ADistributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 812TOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

3.The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis?a.Decreased serum creatinineb.Increased serum lactic acidc.Increased urine specific gravityd.Decreased partial pressure of arterial carbon dioxide

ANS:BThe syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated with acidosis.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 812TOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values)MSC:Integrated Process: Nursing Process (Analysis)

4.A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock?a.Are you more thirsty than normal?b.When was the last time you urinated?c.What is your normal heart rate?d.Is your skin usually cool and pale?

ANS:CThe first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress. The other questions would not identify early stages of shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

5.A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer?a.Normal salineb.Ringers lactatec.5% dextrose in waterd.5% dextrose in 0.45% normal saline

ANS:BRingers lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the clients acidosis.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)MSC:Integrated Process: Nursing Process (Implementation)

6.The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication?a.Decrease in blood pressureb.Increase in heart ratec.Increase in cardiac outputd.Decrease in mean arterial pressure

ANS:CDopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is not a desired response but often occurs as a side effect.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 818TOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)MSC:Integrated Process: Nursing Process (Evaluation)

7.The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client?a.Administer an aminoglycoside.b.Initiate a dopamine hydrochloride (Intropin) drip.c.Administer crystalloid fluids.d.Initiate an intravenous heparin drip.

ANS:CIV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)MSC:Integrated Process: Nursing Process (Evaluation)

8.The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication?a.Ask if the client has chest pain every 30 minutes.b.Assess the clients blood pressure every 15 minutes.c.Monitor the clients urinary output every hour.d.Observe the clients extremities every 4 hours.

ANS:BThe client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the clients pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)MSC:Integrated Process: Nursing Process (Evaluation)

9.The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement?a.Assess the clients respiratory rate.b.Administer the medication with gravity tubing.c.Protect the medication from light with an opaque bag.d.Monitor for hypertensive crisis.

ANS:CSodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)MSC:Integrated Process: Nursing Process (Implementation)

10.The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock?a.Is your blood pressure higher than usual?b.Are you having pain in your throat?c.Have you been vomiting?d.Are you usually this swollen?

ANS:DAnaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)MSC:Integrated Process: Nursing Process (Assessment)

11.A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first?a.Obtain two sets of blood cultures.b.Administer the prescribed IV vancomycin (Vancocin).c.Obtain central venous pressure (CVP) measurements.d.Administer the prescribed IV norepinephrine (Levophed).

ANS:ABlood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies)MSC:Integrated Process: Nursing Process (Implementation)

12.The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the clients shock is caused by sepsis?a.Hypotensionb.Pale clammy skinc.Anxiety and confusiond.Oozing of blood at the IV site

ANS:DThe late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock.


13.A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the clients systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first?a.Insert a Foley catheter to monitor urine output closely.b.Ask the clients family to come to the hospital because death is near.c.Initiate the prescribed dobutamine (Dobutrex) intravenous drip.d.Obtain blood cultures before administering the next dose of antibiotics.

ANS:CThe hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a clients pulse pressure is decreasing rapidly. The family should be updated appropriately.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)MSC:Integrated Process: Nursing Process (Analysis)

14.The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock?a.25-year-old man who has irritable bowel syndromeb.37-year-old woman who is 20% above ideal body weightc.68-year-old woman who is being treated with chemotherapyd.82-year-old man taking beta blockers for hypertension

ANS:CCertain conditions or treatments that cause immune suppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock. The other client situations do not increase the clients risk for septic shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)MSC:Integrated Process: Nursing Process (Assessment)

15.The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed?a.Heparin sodiumb.Vitamin Kc.Corticosteroidsd.Hetastarch (Hespan)

ANS:ADuring the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyExpected Actions/Outcomes)MSC:Integrated Process: Nursing Process (Implementation)

16.The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question?a.Enoxaparin (Lovenox) 40 mg subcutaneous twice dailyb.Transfusion of 2 units of fresh frozen plasmac.Regular insulin intravenous drip per protocold.Cefazolin (Ancef) 1 g IV every 6 hours

ANS:ATherapy during the second (late) phase of septic shock is aimed at enhancing the bloods ability to clot. Enoxaparin would increase the clients risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the clients blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyExpected Actions/Outcomes)MSC:Integrated Process: Nursing Process (Implementation)

17.The nurse is assessing a client at risk for shock. The clients systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first?a.Increase the IV fluid rate.b.Administer oxygen.c.Notify the health care provider.d.Place the client in high Fowlers position.

ANS:BAdministration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. The other interventions should be completed after oxygen is administered.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)MSC:Integrated Process: Nursing Process (Implementation)

18.A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client?a.Clean your toothbrush with laundry bleach daily.b.Bathe every other day with antimicrobial soap.c.Wash your hands after changing pet litter boxes.d.Use an electric razor when you shave your face.

ANS:AThe client at risk for septic shock should be instructed to clean his or her toothbrush daily, either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at higher risk for bleeding disorders.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Nursing Process (Implementation)

19.The nurse is providing community education for clients at risk for dehydration. One client states, We are not at risk because we live in a hot and dry climate. What is the nurses best response?a.You are still at risk but not as high a risk as those who live in hot and humid climates.b.Any type of heat can cause peripheral vasoconstriction, which causes the body to lose water.c.In a hot and dry environment, the body can lose an increased amount of water without your knowledge.d.Even though you are not at risk, you should drink adequate fluids when you exercise.

ANS:CTeach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. Heat causes vasodilation as well, also contributing to water loss. The other statements are not accurate.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)MSC:Integrated Process: Teaching/Learning

20.The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock?a.15-year-old adolescent who plays high school basketballb.24-year-old computer specialist who has bulimiac.48-year-old truck driver who has a 40-pack-year history of smokingd.62-year-old business executive who travels frequently

ANS:BHypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock.


21.The nurse is planning discharge education for a client who had an exploratory laparotomy. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock?a.Monitor how much urine you void and report a decrease in the amount.b.Take your temperature daily and report any below-normal body temperatures.c.Assess your radial pulse every day and report an irregular rhythm.d.Monitor your bowel movements and report ongoing constipation or diarrhea.

ANS:AA decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent. Alterations in temperature, irregular rhythms, and changes in bowel movements are not early signs of shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Teaching/Learning

22.A client who has a local infection of the right forearm is being discharged. The nurse teaches the client to seek immediate medical attention if which complication occurs?a.Dizziness on changing positionb.Increased urine outputc.Warmth and redness at sited.Low-grade temperature

ANS:AWhen a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Teaching/Learning

23.The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis?a.Check blood glucose levels every 4 hours.b.Monitor intake and urinary output twice each shift.c.Decrease ventilator rate and tidal volume.d.Administer prescribed low-dose corticosteroids.

ANS:DDuring severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should include administration of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management)MSC:Integrated Process: Nursing Process (Intervention)

24.The nurse is assessing a client who has septic shock. The following assessment data were collected:

Baseline DataTodays DataHeart rate75 beats/min98 beats/minBlood pressure125/65 mm Hg128/75 mm HgRespiratory rate12 breaths/min18 breaths/minUrinary output40 mL/hr40 mL/hrThe nurse correlates these findings with which stage of shock?a.Earlyb.Compensatoryc.Intermediated.Refractory

ANS:AAn increase in heart and respiratory rates (heart rate first) from the clients baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Analysis)

MULTIPLE RESPONSE

1.The nurse is assessing a client who is in early stages of hypovolemic shock. Which manifestations does the nurse expect? (Select all that apply.)a.Elevated heart rateb.Elevated diastolic blood pressurec.Decreased body temperatured.Elevated respiratory ratee.Decreased pulse rate

ANS:A, B, DHeart and respiratory rates increased from the clients baseline level and a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.

DIF:Cognitive Level: Knowledge/RememberingREF:p. 813TOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

2.The nurse is providing health education to a client on immunosuppressant therapy. Which instructions does the nurse include in this clients teaching? (Select all that apply.)a.Wear a facemask at all times.b.Take your temperature once a day.c.Drink only bottled water.d.Avoid any contact with pets.e.Wash dishes with hot sudsy water.f.Rinse your toothbrush in liquid laundry bleach.

ANS:B, E, FDaily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management)MSC:Integrated Process: Teaching/Learning

3.A client has septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.)a.Decreased cardiac outputb.Increased cardiac outputc.Increased blood glucosed.Decreased blood glucosee.Increased serum lactatef.Decreased serum lactate

ANS:A, C, ESeptic shock manifests with decreased cardiac output, increased blood glucose, and increased serum lactate. The other parameters do not correlate with septic shock.

DIF:Cognitive Level: Comprehension/UnderstandingREF:Table 39-5, p. 823TOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

39

Documents

Transcript of 39