Show Terms in this set (75)Septic Students also viewedCorrect answer: b Students also viewedA. The patient is in the compensatory stage of shock Rationale: Correct Response: d) Burns, a) Dehydration Students also viewed
Terms in this set (60)Which positioning strategy should be used for the client diagnosed with hypovolemic shock? Modified Trendelenburg Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as: sodium nitroprusside. A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as Progressive A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to Encourage the family to touch and talk to the client. A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? Modified Trendelenburg A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Oxygen at 2 L/min by nasal cannula A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is An older adult man with end-stage renal disease and an infected dialysis access site You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client? Increases myocardial contractility You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? Circulatory (distributive) Which of the following is a clinical characteristic of neurogenic shock? Bradycardia A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? neurogenic shock The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? "The client is in shock because the blood volume has decreased in the system." The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? WBC: 42,000/mm3 The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance? Elevate the legs higher than the heart. The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed? Narrowed pulse pressure A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Intubation and mechanical ventilation When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.) Urinary output A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? Morphine The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. 60 mm Hg A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? Epinephrine Which colloid is expensive but rapidly expands plasma volume? Albumin Older adults with impaired cardiac function are more likely to develop which type of shock? Cardiogenic shock Which type of shock occurs from an antigen-antibody response? Anaphylactic A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Lung sounds A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next: Administers oxygen by nasal cannula at 2 liters per minute A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: Jugular venous distention A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: The right foot is cooler than the left foot. A nurse is providing care to all of the following clients. Which would be at increased risk for anaphylactic shock? Select all that apply. The client who is in the first 15 minutes of receiving 1 unit of PRBCs The 55 year-old client with spina bifida The client who reports an allergy to peanuts that causes throat swelling The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Septic The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? Adrenergic drugs Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? Head injury When beta-2 adrenergic receptors are stimulated which of the following occur? Bronchioles relax When vasoactive medications are administered, the nurse must monitor vital signs at least how often? 15 minutes The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? Low Morphine sulfate has which of the following effects on the body? Reduces preload Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. Famotidine
(Pepcid) The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? A rapid, bounding pulse The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption? Maintain activity restriction to bedrest. The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? Mean arterial pressure of 70 mm Hg The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? 5% albumin When a client is in the compensatory stage of shock, which symptom occurs? Tachycardia Explanation: The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the nurse should notify the physician of immediately? The client's heart rate is greater than 90 beats per minute. The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock? Distributive You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock? In the compensation stage, catecholamines are released. Explanation: At what point in shock does metabolic acidosis occur? Decompensation (Progressive) Explanation: A client who is septic has started shivering violently. Which nursing intervention is necessary to care for this client? Control the shivering. Explanation: The nurse is caring for a client in the compensation stage of shock. The nurse knows 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? Restores blood pressure Explanation:
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur? Decompensation (Progressive) A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply. Hypovolemic shock; blood loss Cardiogenic shock; myocardial infarction Anaphylactic shock; nuts Septic shock; infection The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply. Vital signs The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report? 24 Explanation: The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock? Septic Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage? Albumin A client is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is cool and clammy. Which medical order for this client will the nurse complete first? 100% oxygen via a nonrebreather mask A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which assessment finding indicates that the client may be experiencing neurogenic shock? HR, 48 bpm; BP, 90/60 mm Hg Explanation: What can the nurse include in the plan of care to ensure early intervention along the continuum of shock to improve the client's prognosis? Select all that apply. Assess the client who is at risk for shock. Administer intravenous fluids. Monitor for changes in vital signs. The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 70% Explanation: The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient? The patient has developed a stress ulcer that is bleeding. Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: Blood pressure Explanation: The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by: Cold, clammy skin and tachycardia. Explanation: Students also viewedChapter 14: Shock PrepU41 terms KaylieNacolee Ch. 14: Shock & Multiple Organ Dysfunction Syndrome60 terms JDMci Med-Surge Nursing Shock Prep U ch. 1492 terms Andy_Polanco Chapter 54: PrepU - Nursing Management: Shock and…83 terms welchamber11 Sets found in the same folderPrep-U Chapter 14: Shock and Multiple Organ Dysfun…57 terms Halie_McGee Complex Ch 14: Shock65 terms TaylorSublett Ch 14 Shock and MODS18 terms ellelor Chapter 14 AC20 terms latbat0960 Other sets by this creatorChapter 72: Emergency Nursing (Working)20 terms cjspencer Chapter 36: Management of Patients With Immune Def…59 terms cjspencer Emergencies64 terms cjspencer Chapter 70: Management of Patients With Oncologic…40 terms cjspencer Recommended textbook solutions Clinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
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What are the characteristics of shock quizlet?Shock is defined as a physiologic state characterized by inadequate tissue perfusion to meet metabolic demand and tissue oxygenation. How can shock be characterized? By inadequate peripheral and end organ perfusion. Also it can be characterized by low cardiac output and decreased level of consciousness.
Which of the following are general signs and symptoms of shock select all that apply?Signs and symptoms of shock vary depending on circumstances and may include:. Cool, clammy skin.. Pale or ashen skin.. Bluish tinge to lips or fingernails (or gray in the case of dark complexions). Rapid pulse.. Rapid breathing.. Nausea or vomiting.. Enlarged pupils.. Weakness or fatigue.. What general classification of shock includes neurogenic shock?Distributive shock is caused by an abnormal distribution of blood to tissues and organs and includes septic, anaphylactic, and neurogenic causes.
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The clinical characteristics of neurogenic shocks are signs of stimulation quizlet
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