ICU EXAM 2

A nurse is assessing a patient suspected of having systemic inflammatory response syndrome (SIRS). Which findings meet the diagnostic criteria?

A. Fever, tachycardia, and tachypnea
B. Hypothermia, bradycardia, and hypertension
C. Hypertension, normal respirations, and leukocytosis
D. Tachycardia, bradycardia, and decreased urine output

Correct Answer: A

Rationale

SIRS is diagnosed when two or more of the following criteria are present:

• Temperature >38°C or <36°C

• Tachycardia

• Tachypnea (RR >20)

Abnormal WBC count (>12,000, <4,000, or >10% bands)

Option A contains three SIRS criteria: fever, tachycardia, and tachypnea.

Why the other answers are incorrect

• B: Bradycardia and hypertension are not SIRS criteria.

• C: Hypertension is not part of SIRS criteria.

• D: Bradycardia is not a SIRS sign.

A nurse understands that sepsis is diagnosed when which condition occurs?

A. SIRS without infection
B. SIRS plus a suspected or confirmed infection
C. Fever with hypotension
D. Elevated lactate without infection

Correct Answer: B

Rationale

Sepsis occurs when:

SIRS + suspected or confirmed infection.

This means the patient has systemic inflammation and a known infectious source.

Why the other answers are incorrect

• A: This describes SIRS, not sepsis.

• C: Fever and hypotension alone do not define sepsis.

• D: Elevated lactate alone is not diagnostic for sepsis.

A patient with sepsis begins to develop sudden confusion, decreased urine output, and lactate of 3 mmol/L. The nurse recognizes this condition as:

A. SIRS
B. Sepsis
C. Severe sepsis
D. Septic shock

Correct Answer: C

Rationale

Severe sepsis occurs when sepsis causes acute organ dysfunction.

Signs include:

• Abrupt mental status change

• Decreased urine output

• Elevated lactate (>2)

• Hemodynamic instability

• Mottled skin

  FA25 Chapter 11 - Shock (S) - T…

The patient in the scenario has organ dysfunction, indicating severe sepsis.

Why the other answers are incorrect

• A: SIRS does not require infection or organ dysfunction.

• B: Sepsis is infection with SIRS but without organ failure.

• D: Septic shock requires persistent hypotension despite fluids.

A nurse is reviewing the pathophysiology of sepsis. Which process occurs first in the development of sepsis?

A. Vasodilation and fluid leakage
B. Activation of the immune response
C. Systemic organ failure
D. Coagulation cascade impairment

Correct Answer: B

Rationale

The progression of sepsis begins with:

1. Infection (insult)

2. Immune response activation

3. Cytokine and mediator release

4. Increased capillary permeability

5. Fluid leakage and hypovolemia

6. Vasodilation

7. Impaired coagulation cascade

8. Poor tissue perfusion

   FA25 Chapter 11 - Shock (S) - T…

Therefore, the first step after infection is activation of the immune system.

Why the other answers are incorrect

• A: Vasodilation occurs later in the process.

• C: Organ failure occurs much later in the progression.

• D: Coagulation dysfunction happens after inflammatory mediator release.

A nurse is caring for a patient with sepsis. Which finding is most concerning for worsening tissue perfusion?

A. Capillary refill less than 2 seconds
B. Urine output of 45 mL/hr
C. Mottled skin and decreased urine output
D. Warm skin and stable blood pressure

Correct Answer: C

Rationale

Signs of worsening sepsis and poor tissue perfusion include:

• Decreased urine output

• Mottled skin

• Delayed capillary refill

• Hemodynamic instability

• Mental status changes

• Elevated lactate

  FA25 Chapter 11 - Shock (S) - T…

These signs indicate organ dysfunction and worsening perfusion.

Why the other answers are incorrect

• A: Capillary refill <2 seconds is normal.

• B: Urine output of 45 mL/hr is adequate.

• D: Warm skin with stable BP is not a sign of worsening perfusion.

A nurse is caring for a patient with sepsis. Which population is considered most at risk for developing sepsis?

A. Healthy young adults
B. Post-operative patients
C. Athletes
D. Adolescents

Correct Answer: B

Rationale

Patients at highest risk for sepsis include:

• Elderly patients

• Surgical patients

• Immunocompromised individuals

• Patients with chronic illness

• Premature infants

  FA25 Chapter 11 - Shock (S) - T…

Post-operative patients are particularly vulnerable because surgery can introduce infection and weaken immune defenses.

Why the other answers are incorrect

• A: Healthy adults have lower risk.

• C: Athletes typically have strong immune systems.

• D: Adolescents are not a high-risk group unless immunocompromised.

A patient with suspected sepsis develops a sudden change in mental status and a lactate level of 2.8 mmol/L. Which interpretation by the nurse is most accurate?

A. The patient is experiencing septic shock
B. The findings are expected and not concerning
C. The patient is progressing to severe sepsis
D. The patient remains in the SIRS stage

Correct Answer:
C. The patient is progressing to severe sepsis

Rationale

Severe sepsis occurs when sepsis leads to organ dysfunction.

Signs include:

• Sudden change in mental status

• Elevated lactate (>2 mmol/L)

• Hemodynamic instability

• Decreased urine output

• Mottled skin

• Capillary refill >3 seconds

This patient has:

• Altered mental status

• Elevated lactate

Both indicate organ dysfunction, which defines severe sepsis.

Why the other answers are incorrect

• A: Septic shock requires persistent hypotension after fluid resuscitation.

• B: These findings indicate worsening perfusion and are concerning.

• D: SIRS does not include organ dysfunction.

A nurse is assessing a patient suspected of sepsis. Which finding would indicate early organ dysfunction?

A. Temperature 38.2°C
B. Respiratory rate 22/min
C. Sudden change in mental status
D. Heart rate 102 bpm

Correct Answer: C

Rationale

One of the earliest signs of organ dysfunction in sepsis is a change in mental status.

Signs of severe sepsis with organ dysfunction include:

• Sudden mental status change

• Hemodynamic instability

• Decreased urine output

• Capillary refill >3 seconds

• Elevated lactate

• Mottled skin

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Mental status changes occur because poor tissue perfusion reduces oxygen delivery to the brain.

Why the other answers are incorrect

• A: Fever is part of SIRS criteria but does not indicate organ dysfunction.

• B: Tachypnea is a SIRS criterion.

• D: Tachycardia is also a SIRS criterion.

A patient with suspected sepsis has the following findings:

• Temperature: 39°C

• Respiratory rate: 24/min

• WBC: 13,000/mm³

• Confirmed pneumonia

Which interpretation by the nurse is correct?

A. The patient has SIRS only
B. The patient meets criteria for sepsis
C. The patient is experiencing severe sepsis
D. The patient is in septic shock

Correct Answer: B

Rationale

SIRS requires 2 or more of the following:

• Temperature >38°C or <36°C

• Tachycardia

• Tachypnea (>20)

• Abnormal WBC (>12,000 or <4,000)

  FA25 Chapter 11 - Shock (S) - T…

This patient has:

• Fever

• Tachypnea

• Elevated WBC

These meet SIRS criteria.

Because there is also a confirmed infection (pneumonia), the condition meets the definition of sepsis.

Why the other answers are incorrect

• A: SIRS requires inflammation but no infection.

• C: Severe sepsis requires organ dysfunction.

• D: Septic shock requires persistent hypotension after fluids.

A patient with sepsis begins to develop mottled skin, decreased urine output, and capillary refill greater than 3 seconds. The nurse recognizes these findings as:

A. SIRS
B. Sepsis
C. Severe sepsis
D. Septic shock

Correct Answer:
C. Severe sepsis

Rationale

Severe sepsis occurs when sepsis causes organ dysfunction and impaired tissue perfusion.

Signs of severe sepsis include:

• Capillary refill >3 seconds

• Decreased urine output

• Mottled skin

• Hemodynamic instability

• Sudden change in mental status

• Elevated lactate

  FA25 Chapter 11 - Shock (S) - T…

These findings indicate that organs are not receiving adequate perfusion.

Why the other answers are incorrect

• A. SIRS → inflammation without infection

• B. Sepsis → infection with SIRS but no organ dysfunction

• D. Septic shock → requires persistent hypotension after fluids

A patient with sepsis suddenly becomes confused and produces only 20 mL of urine over the last hour. What is the nurse’s priority interpretation?

A. The patient is improving
B. The patient is progressing to severe sepsis
C. The patient is experiencing dehydration only
D. The patient is stable

Correct Answer:
B. The patient is progressing to severe sepsis

Rationale

Two key indicators of organ dysfunction are present:

• Altered mental status

• Decreased urine output

Both findings indicate impaired tissue perfusion and organ dysfunction, which defines severe sepsis.

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Immediate intervention is necessary to prevent progression to septic shock.

Why the other answers are incorrect

• A: These findings indicate deterioration, not improvement.

• C: Dehydration alone would not explain mental status changes.

• D: The patient is not stable due to signs of organ dysfunction

A patient with sepsis has received IV fluids but remains hypotensive. The nurse notes the following findings:

• MAP: 55 mmHg

• Lactate: 4.5 mmol/L

• Oliguria

The nurse recognizes these findings as:

A. SIRS
B. Sepsis
C. Severe sepsis
D. Septic shock

Correct Answer:
D. Septic shock

Rationale

Septic shock occurs when hypotension persists after fluid resuscitation and tissue perfusion remains inadequate.

Key indicators include:

• MAP < 60 mmHg

• Lactate > 4 mmol/L

• Need for vasopressors

• Persistent hypotension despite fluids

  FA25 Chapter 11 - Shock (S) - T…

This patient meets those criteria.

Why the other answers are incorrect

• A: SIRS involves inflammatory criteria only.

• B: Sepsis involves infection + SIRS but not persistent hypotension.

• C: Severe sepsis includes organ dysfunction but not necessarily refractory hypotension.

A patient is diagnosed with septic shock. Which intervention should the nurse anticipate first?

A. Administer isotonic IV fluids rapidly
B. Begin enteral feeding
C. Administer sedatives
D. Encourage ambulation

Correct Answer:
A. Administer isotonic IV fluids rapidly

Rationale

The first treatment priority in septic shock is rapid fluid resuscitation to restore circulating volume and improve tissue perfusion.

The slides emphasize:

• Rapid isotonic fluid administration

• Restore perfusion and maintain blood pressure

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Fluids help counteract vasodilation and capillary leakage seen in septic shock.

Why the other answers are incorrect

• B: Nutrition is not the immediate priority.

• C: Sedatives do not treat the underlying perfusion problem.

• D: Ambulation is inappropriate for unstable patients.

A patient with septic shock does not respond adequately to fluid resuscitation. Which medication does the nurse expect to administer next?

A. Acetaminophen
B. Norepinephrine
C. Insulin
D. Furosemide

Correct Answer:
B. Norepinephrine

Rationale

If fluids do not restore blood pressure, vasopressors are used to increase vascular tone and maintain perfusion.

Common vasopressors used in septic shock include:

• Norepinephrine

• Vasopressin

• Epinephrine

• Phenylephrine

• Dobutamine

Norepinephrine is commonly used to increase systemic vascular resistance and raise blood pressure.

Why the other answers are incorrect

• A: Treats fever but not shock.

• C: Used for hyperglycemia.

• D: Diuretics would worsen hypotension.

A nurse suspects a patient may be developing Systemic Inflammatory Response Syndrome (SIRS). Which findings meet the diagnostic criteria for SIRS?
(Select all that apply)

A. Temperature 39°C
B. Respiratory rate 24/min
C. Heart rate 110 bpm
D. WBC 14,500/mm³
E. Blood pressure 150/90

Correct Answers:
A, B, C, D

Rationale

SIRS is diagnosed when 2 or more of the following criteria are present:

• Temperature >38°C or <36°C

• Tachycardia

• Tachypnea (RR >20)

• Abnormal WBC (>12,000 or <4,000 or >10% bands)

  FA25 Chapter 11 - Shock (S) - T…

Therefore:

• A: Fever ✔

• B: Tachypnea ✔

• C: Tachycardia ✔

• D: Leukocytosis ✔

• E: Blood pressure is not part of SIRS criteria

A patient presents with the following findings:

• Temperature: 35.8°C

• Heart rate: 104 bpm

• Respiratory rate: 22/min

• WBC: 7,000/mm³

How should the nurse interpret these findings?

A. The patient does not meet criteria for SIRS
B. The patient meets criteria for SIRS
C. The patient has severe sepsis
D. The patient is in septic shock

Correct Answer:
B. The patient meets criteria for SIRS

Rationale

The patient meets 3 SIRS criteria:

• Temperature <36°C

• Tachycardia

• Tachypnea

  FA25 Chapter 11 - Shock (S) - T…

SIRS requires two or more criteria, so this patient meets the definition.

Why the other answers are incorrect

• A: The patient clearly meets SIRS criteria.

• C: Severe sepsis requires organ dysfunction.

• D: Septic shock requires persistent hypotension after fluids.

A nurse understands that SIRS differs from sepsis because SIRS:

A. Always involves infection
B. Occurs only in trauma patients
C. Can occur without infection
D. Always results in organ failure

Correct Answer:
C. Can occur without infection

Rationale

SIRS is a systemic inflammatory response that may occur due to many causes, including:

• Infection

• Trauma

• Burns

• Surgery

  FA25 Chapter 11 - Shock (S) - T…

When infection is present with SIRS, the condition becomes sepsis.

Why the other answers are incorrect

• A: Infection is required for sepsis, not SIRS.

• B: Trauma is only one possible cause.

• D: Organ failure occurs later in severe sepsis.

A nurse is caring for a patient who lost a large amount of blood after surgery. The patient develops the following findings:

• HR: 128 bpm

• BP: 86/50

• Cool, clammy skin

• Urine output: 15 mL/hr

Which nursing intervention is the priority?

A. Administer rapid isotonic IV fluids
B. Encourage oral fluid intake
C. Administer antipyretics
D. Place the patient in Trendelenburg position

tput 45 mL/hr

This is considered adequate urine output.

B. Capillary refill <2 seconds

This indicates normal perfusion.

D. Heart rate decreasing to 90 bpm

A decrease toward normal may indicate improvement rather than worsening shock

Correct Answer:
A. Administer rapid isotonic IV fluids

Rationale

Hypovolemic shock occurs when circulating blood volume is significantly reduced, leading to decreased tissue perfusion.

FA25 Chapter 11 - Shock (S) - T…

Classic findings include:

• Tachycardia

• Hypotension

• Cool clammy skin

• Decreased urine output

• Altered mental status

  FA25 Chapter 11 - Shock (S) - T…

The priority treatment is rapid fluid replacement to restore intravascular volume.

Common fluids include:

• Normal saline

• Lactated Ringer’s

  FA25 Chapter 11

A nurse is caring for a patient who lost a large amount of blood after surgery. The patient develops the following findings:

• HR: 128 bpm

• BP: 86/50

• Cool, clammy skin

• Urine output: 15 mL/hr

Which nursing intervention is the priority?

A. Administer rapid isotonic IV fluids
B. Encourage oral fluid intake
C. Administer antipyretics
D. Place the patient in Trendelenburg position

Correct Answer:
A. Administer rapid isotonic IV fluids

Rationale

Hypovolemic shock occurs when circulating blood volume is significantly reduced, leading to decreased tissue perfusion.

FA25 Chapter 11 - Shock (S) - T…

Classic findings include:

• Tachycardia

• Hypotension

• Cool clammy skin

• Decreased urine output

• Altered mental status

  FA25 Chapter 11 - Shock (S) - T…

The priority treatment is rapid fluid replacement to restore intravascular volume.

Common fluids include:

• Normal saline

• Lactated Ringer’

A patient arrives in the emergency department after several days of severe vomiting and diarrhea. The nurse suspects hypovolemic shock. Which assessment finding best supports this diagnosis?

A. Warm flushed skin
B. Bounding peripheral pulses
C. Tachycardia and hypotension
D. Hypertension and bradycardia

Correct Answer:
C. Tachycardia and hypotension

Rationale

Hypovolemic shock results from loss of circulating fluid volume due to conditions such as:

• Vomiting

• Diarrhea

• Hemorrhage

• Burns

• Trauma

  FA25 Chapter 11 - Shock (S) - T…

The body compensates by activating the sympathetic nervous system, which causes:

• Tachycardia

• Peripheral vasoconstriction

• Decreased urine output

As shock worsens, hypotension develops due to inadequate circulating volume.

A nurse is monitoring a patient with hypovolemic shock. Which finding indicates worsening tissue perfusion?

A. Urine output 45 mL/hr
B. Capillary refill less than 2 seconds
C. Increasing confusion and oliguria
D. Heart rate decreasing to 90 bpm

Correct Answer:
C. Increasing confusion and oliguria

Rationale

As hypovolemic shock progresses, tissue perfusion decreases, leading to organ dysfunction.

Late findings include:

• Altered mental status

• Decreased urine output

• Hypotension

• Cool clammy skin

• Dyspnea

  FA25 Chapter 11 - Shock (S) - T…

Confusion occurs due to decreased cerebral perfusion, while oliguria indicates reduced kidney perfusion.

Both findings signal worsening shock and potential organ failure.

Question 4 (Multiple Choice)
A nurse is assessing a patient with suspected hypovolemic shock following trauma. Which assessment finding is most consistent with the compensatory stage of hypovolemic shock?
A. Bradycardia and hypertension
B. Tachycardia and restlessness
C. Warm flushed skin and bounding pulses
D. Decreased respiratory rate

Correct Answer: B

Rationale: Hypovolemic shock occurs when circulating blood volume is reduced, resulting in decreased tissue perfusion.

The body initially activates the sympathetic nervous system to compensate for decreased cardiac output. Early compensatory findings include tachycardia, restlessness, anxiety, tachypnea, and pale skin as the body attempts to maintain perfusion to vital organs.

Tachycardia helps increase cardiac output, while restlessness occurs due to decreased cerebral perfusion. The other options are incorrect because bradycardia is not typical in early shock, warm flushed skin is more associated with early septic shock, and respiratory rate typically increases rather than decreases during hypovolemic shock.

A nurse is caring for a patient with hypovolemic shock caused by gastrointestinal bleeding. Which assessment finding indicates the most immediate need for intervention?
A. Heart rate 112 bpm
B. Blood pressure 92/60 mmHg
C. Urine output 12 mL/hr
D. Respiratory rate 24/min

Correct Answer: C

Rationale: Hypovolemic shock results in decreased circulating blood volume and reduced organ perfusion. A key indicator of worsening perfusion is decreased urine output, which reflects reduced kidney perfusion. The shock material lists decreased urine output, hypotension, tachycardia, cool clammy skin, dyspnea, and altered mental status as significant findings in hypovolemic shock.

FA25 Chapter 11 - Shock (S) - T…

Urine output less than 30 mL/hr suggests inadequate renal perfusion and indicates worsening shock requiring immediate intervention. Tachycardia and tachypnea are compensatory mechanisms and may appear earlier, while hypotension alone does not necessarily indicate organ failure as clearly as oliguria does.

A patient arrives at the emergency department with severe dehydration from prolonged diarrhea. Assessment findings include: HR 124 bpm, BP 84/52 mmHg, cool clammy skin, and delayed capillary refill. Which pathophysiologic process is primarily responsible for these findings?

A. Increased systemic vascular resistance from vasodilation
B. Decreased circulating volume leading to reduced cardiac output
C. Increased pulmonary artery pressure causing reduced perfusion
D. Increased preload causing decreased tissue perfusion

Correct Answer: B

Rationale: Hypovolemic shock occurs when significant loss of fluid or blood decreases circulating volume, which leads to reduced venous return to the heart. This decreases stroke volume and cardiac output, ultimately causing decreased tissue perfusion and cellular hypoxia.

FA25 Chapter 11 - Shock (S) - T…

The patient’s symptoms—tachycardia, hypotension, cool clammy skin, and delayed capillary refill—are classic manifestations of the body attempting to compensate for decreased blood volume. Vasodilation is associated more with distributive shock such as septic shock, pulmonary artery pressure relates to cardiogenic or pulmonary conditions, and increased preload would not occur in hypovolemic shock because circulating volume is reduced

A patient with a history of myocardial infarction develops cardiogenic shock. Which assessment finding is most consistent with this condition?
A. Warm flushed skin and bounding pulses
B. Hypotension, pulmonary crackles, and jugular venous distention
C. Tachycardia with dry mucous membranes and decreased skin turgor
D. Hypertension and bradycardia

Correct Answer: B

Rationale: Cardiogenic shock occurs when the heart cannot pump effectively, leading to decreased cardiac output and poor tissue perfusion. Common manifestations include hypotension, pulmonary congestion (crackles), jugular venous distention, dyspnea, tachycardia, oliguria, and anxiety.

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Pulmonary crackles occur because blood backs up into the lungs when the left ventricle cannot pump effectively. JVD indicates increased venous pressure due to heart failure. Option A is more consistent with early septic shock. Option C describes hypovolemic shock from dehydration or fluid loss. Option D does not reflect typical findings in cardiogenic shock.

A nurse is caring for a patient with cardiogenic shock following an acute myocardial infarction. Which intervention is most important to improve tissue perfusion?
A. Administer medications that improve cardiac output
B. Encourage oral fluid intake
C. Position the patient flat in bed
D. Administer diuretics immediately

Correct Answer: A

Rationale: The primary problem in cardiogenic shock is pump failure, meaning the heart cannot effectively circulate blood. Treatment therefore focuses on improving cardiac output and supporting circulation. This may include vasoactive medications and mechanical circulatory support such as intra-aortic balloon pump (IABP) or ventricular assist devices (VAD).

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Encouraging oral fluids will not correct pump failure and may worsen pulmonary congestion. Lying flat may worsen breathing due to pulmonary congestion. Diuretics may sometimes be used for pulmonary edema but are not the primary intervention to restore cardiac output.

A nurse is monitoring a patient with cardiogenic shock. Which finding indicates worsening cardiac output and tissue perfusion?
A. Urine output 40 mL/hr
B. Increasing dyspnea and oliguria
C. Blood pressure 120/76 mmHg
D. Capillary refill less than 2 seconds

Correct Answer: B

Rationale: Cardiogenic shock leads to decreased cardiac output, resulting in poor perfusion of organs. Key signs include dyspnea from pulmonary congestion and decreased urine output due to reduced renal perfusion.

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Oliguria indicates that the kidneys are not receiving adequate blood flow. Urine output of 40 mL/hr (A) is considered adequate. A normal blood pressure (C) and normal capillary refill (D) suggest adequate perfusion rather than worsening shock.

A patient with a large anterior myocardial infarction develops the following findings: BP 82/48 mmHg, HR 118 bpm, crackles in both lung bases, cool clammy skin, and urine output 18 mL/hr. Which mechanism is primarily responsible for the patient’s condition?
A. Loss of circulating blood volume
B. Failure of the heart to pump effectively
C. Systemic vasodilation caused by infection
D. Increased pulmonary vascular resistance

Correct Answer: B

Rationale: Cardiogenic shock occurs when the heart cannot pump effectively, resulting in decreased cardiac output and inadequate tissue perfusion.

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A myocardial infarction damages heart muscle, reducing contractility and stroke volume. This leads to hypotension, poor perfusion (cool clammy skin), decreased urine output, and pulmonary congestion because blood backs up into the lungs when the left ventricle fails. Option A describes hypovolemic shock. Option C describes septic shock. Option D may contribute to pulmonary issues but is not the primary cause of cardiogenic shock.

A nurse is caring for a patient with cardiogenic shock who suddenly becomes more short of breath. Lung auscultation reveals worsening crackles. What is the most appropriate interpretation of this finding?
A. The patient is improving
B. Fluid is backing up into the lungs due to pump failure
C. The patient is experiencing dehydration
D. The patient has developed hypovolemic shock

Correct Answer: B

Rationale: Cardiogenic shock leads to pump failure, which causes blood to back up into the pulmonary circulation when the left ventricle cannot pump effectively. This results in pulmonary congestion and crackles, along with dyspnea.

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These symptoms indicate worsening cardiac output and pulmonary edema. Dehydration or hypovolemia would more likely cause dry lungs rather than crackles.

A patient with cardiogenic shock is being monitored closely. Which assessment finding most strongly suggests impaired organ perfusion due to decreased cardiac output?
A. Urine output 50 mL/hr
B. Blood pressure 118/70 mmHg
C. Increasing anxiety with urine output of 15 mL/hr
D. Respiratory rate 18/min

Correct Answer: C

Rationale: Cardiogenic shock results in decreased cardiac output and poor tissue perfusion, which leads to organ dysfunction.

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Key indicators of impaired perfusion include decreased urine output (oliguria) and altered mental status such as anxiety or confusion, both caused by reduced blood flow to the kidneys and brain. A urine output of 50 mL/hr is adequate. A normal blood pressure and normal respiratory rate do not suggest worsening perfusion.

A patient with a spinal cord injury at T4 develops hypotension. The nurse notes HR 48 bpm and warm dry skin. Which type of shock is most likely occurring?
A. Hypovolemic shock
B. Cardiogenic shock
C. Septic shock
D. Neurogenic shock

Correct Answer: D

Rationale: Neurogenic shock occurs when there is loss of sympathetic nervous system control, most commonly from spinal cord injury (often at T6 or above). This causes vasodilation, decreased vascular tone, hypotension, and bradycardia.

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Unlike most other shock states that produce tachycardia and cool clammy skin, neurogenic shock presents with bradycardia and warm dry skin due to peripheral vasodilation and unopposed parasympathetic activity. Hypovolemic and cardiogenic shock usually cause tachycardia and cool clammy skin. Septic shock may cause warm skin but typically presents with tachycardia rather than bradycardia.

A patient with neurogenic shock develops severe bradycardia with a heart rate of 40 bpm. Which medication should the nurse anticipate administering?
A. Norepinephrine
B. Atropine
C. Furosemide
D. Insulin

Correct Answer: B

Rationale: Neurogenic shock causes loss of sympathetic nervous system activity, which results in bradycardia due to unopposed vagal (parasympathetic) activity. Treatment focuses on restoring vascular tone and supporting heart rate. Atropine is commonly used to treat symptomatic bradycardia in neurogenic shock.

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Norepinephrine may be used to improve blood pressure, but atropine directly treats the bradycardia. Furosemide is a diuretic and would worsen hypotension. Insulin is unrelated to the treatment of neurogenic shock.

A nurse is caring for a patient with neurogenic shock following a spinal cord injury. Which assessment finding indicates worsening perfusion and requires immediate intervention?
A. Urine output 45 mL/hr
B. Blood pressure 78/44 mmHg with increasing lethargy
C. Respiratory rate 20/min
D. Capillary refill less than 2 seconds

Correct Answer: B

Rationale: Neurogenic shock causes vasodilation and decreased cardiac output, leading to hypotension and decreased tissue perfusion.

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A blood pressure of 78/44 mmHg with worsening mental status indicates poor cerebral perfusion and progression of shock. Altered mental status is a significant indicator of inadequate perfusion. Urine output of 45 mL/hr suggests adequate kidney perfusion. A respiratory rate of 20 is within normal limits, and capillary refill less than 2 seconds indicates adequate perfusion rather than worsening shock.

A nurse is assessing four patients with hypotension. Which patient presentation is most consistent with neurogenic shock?
A. BP 84/50, HR 126, cool clammy skin, history of severe dehydration
B. BP 82/48, HR 118, crackles in lungs, history of myocardial infarction
C. BP 86/52, HR 44, warm dry skin, recent cervical spinal cord injury
D. BP 88/54, HR 122, fever 39°C, suspected infection

Correct Answer: C

Rationale: Neurogenic shock occurs when there is loss of sympathetic nervous system control, commonly from spinal cord injury, leading to vasodilation, hypotension, and bradycardia.

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The key distinguishing features are bradycardia and warm dry skin, which occur because sympathetic tone is lost and parasympathetic activity becomes dominant. Option A represents hypovolemic shock (tachycardia and fluid loss). Option B represents cardiogenic shock (pump failure with pulmonary congestion). Option D represents septic shock (infection with fever and tachycardia).

A nurse is reviewing the mechanism of neurogenic shock. Which physiologic change primarily causes the severe hypotension seen in this condition?
A. Increased cardiac contractility
B. Peripheral vasodilation due to loss of sympathetic tone
C. Decreased circulating blood volume
D. Pulmonary artery obstruction

Correct Answer: B

Rationale: Neurogenic shock results from disruption of sympathetic nervous system pathways, most commonly after spinal cord injury. This leads to loss of vascular tone and widespread vasodilation, causing blood to pool in the peripheral circulation.

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The resulting decrease in venous return reduces cardiac output and leads to severe hypotension. Decreased blood volume describes hypovolemic shock, and pulmonary obstruction is associated with obstructive shock.

A patient with a spinal cord injury is diagnosed with neurogenic shock. Which assessment finding best explains why this patient develops bradycardia instead of tachycardia, unlike most other shock states?
A. Activation of the renin-angiotensin system
B. Increased circulating catecholamines
C. Unopposed parasympathetic stimulation of the heart
D. Increased preload to the right ventricle

Correct Answer: C

Rationale: In neurogenic shock, sympathetic nervous system activity is lost due to spinal cord injury, leaving parasympathetic (vagal) stimulation unopposed.

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This results in bradycardia, which is unique compared to other forms of shock where tachycardia is typically present as a compensatory response. The renin-angiotensin system and catecholamines normally increase heart rate and vascular tone, which would cause tachycardia rather than bradycardia. Increased preload does not explain the heart rate change seen in neurogenic shock.

A nurse is assessing four patients. Which patient is most likely experiencing anaphylactic shock?

A. BP 90/60, HR 120, warm flushed skin, fever
B. BP 80/50, HR 118, wheezing, urticaria, facial swelling
C. BP 86/54, HR 110, cool clammy skin, decreased urine output
D. BP 88/60, HR 62, warm dry skin, spinal cord injury

Correct Answer: B. BP 80/50, HR 118, wheezing, urticaria, facial swelling

Rationale

Classic signs of anaphylactic shock include:

• Hypotension

• Respiratory distress (wheezing, bronchospasm)

• Urticaria or flushing

• Angioedema (facial swelling)

These symptoms occur due to massive histamine release causing vasodilation and airway edema.

Why the other answers are incorrect:

• A → Septic shock (warm skin + infection signs).

• C → Hypovolemic shock (cool, clammy skin + fluid loss).

• D → Neurogenic shock (bradycardia + spinal cord injury).

A patient in anaphylactic shock has received epinephrine IM. Which intervention should the nurse anticipate next?

A. Administer IV furosemide
B. Administer IV diphenhydramine
C. Administer insulin infusion
D. Administer beta blockers

Correct Answer: B. Administer IV diphenhydramine

Rationale

After epinephrine, the next medications typically include:

• Antihistamines (diphenhydramine)

• Corticosteroids

• Bronchodilators

• IV fluids

Diphenhydramine blocks histamine receptors, helping reduce:

• hives

• swelling

• allergic response progression

Why the other answers are incorrect:

• A. Furosemide → used for fluid overload, not allergic reactions.

• C. Insulin → used for hyperglycemia or DKA.

• D. Beta blockers → can worsen bronchospasm and hypotension in anaphylaxis.

A patient arrives in the emergency department with a blood pressure of 212/128 mmHg. The patient reports a severe headache, blurred vision, and confusion. Which finding indicates that the patient is experiencing a hypertensive crisis with end-organ damage?

A. Heart rate of 92 bpm
B. Blurred vision and confusion
C. Temperature of 37.3°C (99.1°F)
D. Respiratory rate of 18/min

Correct Answer: B

Rationale:
A hypertensive crisis occurs when SBP >180 mmHg or DBP >120 mmHg with evidence of acute organ damage. Common manifestations include severe headache, confusion, blurred vision, seizures, nausea/vomiting, and oliguria.

Sp26 Chapter 23, 24 - Perfusion…

Blurred vision and confusion suggest neurologic involvement from cerebral edema, indicating end-organ damage. A heart rate of 92 bpm, normal respiratory rate, and mild temperature changes do not indicate organ damage.

A patient diagnosed with hypertensive crisis is admitted to the ICU. Which nursing intervention is the highest priority during the acute phase of treatment?

A. Monitor blood pressure every 5–15 minutes
B. Encourage ambulation to prevent complications
C. Restrict oral fluids
D. Provide a high-sodium diet

Correct Answer: A

Rationale:
Patients with hypertensive crisis require frequent monitoring of blood pressure, cardiac rhythm, urine output, and neurological status. Blood pressure is typically monitored every 5–15 minutes to evaluate the effectiveness of IV antihypertensive medications and prevent complications.

Sp26 Chapter 23, 24 - Perfusion…

Ambulation is not appropriate during the acute phase. Sodium intake should not be increased because it can worsen hypertension. Fluid restriction is not a priority unless specifically ordered.

A nurse is reviewing the pathophysiology of hypertensive crisis. Which condition occurs because autoregulation of blood flow fails during extremely elevated blood pressure?

A. Pulmonary embolism
B. Cerebral edema
C. Hypoglycemia
D. Metabolic alkalosis

Correct Answer: B

Rationale:
In hypertensive crisis, autoregulation mechanisms fail, leading to excessive pressure within blood vessels and damage to organs. This can cause cerebral edema, acute kidney injury, and cardiac complications such as myocardial infarction or heart failure.

Sp26 Chapter 23, 24 - Perfusion…

Pulmonary embolism, hypoglycemia, and metabolic alkalosis are not direct consequences of hypertensive crisis pathophysiology.

A patient with hypertensive crisis suddenly reports severe chest pain and shortness of breath. Which complication is the nurse most concerned about?

A. Acute myocardial infarction
B. Hypoglycemia
C. Pulmonary infection
D. Anemia

Correct Answer: A

Rationale:
Hypertensive crisis can cause acute organ damage, including myocardial infarction, heart failure, stroke, cerebral edema, aortic dissection, acute kidney injury, and retinopathy.

Sp26 Chapter 23, 24 - Perfusion…

Chest pain and shortness of breath are classic signs of cardiac involvement, particularly myocardial infarction or acute heart failure. Hypoglycemia, infection, and anemia are not typical complications of hypertensive crisis.

A patient with hypertensive crisis is receiving IV antihypertensive medication in the ICU. Which assessment finding best indicates that treatment is effective?

A. Blood pressure decreases gradually to 168/98 mmHg
B. Blood pressure drops rapidly to 90/50 mmHg
C. Heart rate increases to 130 bpm
D. Respiratory rate increases to 28/min

Correct Answer: A

Rationale:
Treatment of hypertensive crisis requires controlled reduction of blood pressure, typically with IV antihypertensive medications and close monitoring.

Sp26 Chapter 23, 24 - Perfusion…

A gradual decrease in BP indicates effective therapy while preventing sudden drops that could cause decreased perfusion to the brain, heart, and kidneys. A rapid drop to 90/50 mmHg could cause ischemia and organ damage. Increasing heart rate or respiratory rate does not indicate effective BP control.

A patient arrives at the emergency department complaining of crushing chest pain radiating to the left arm and jaw that began 1 hour ago while walking. The patient is diaphoretic and anxious. Which finding most strongly supports the diagnosis of acute myocardial infarction?

A. Blood pressure of 150/90 mmHg
B. Troponin level of 0.02 ng/mL
C. Troponin level of 1.2 ng/mL
D. Respiratory rate of 20/min

Correct Answer: C

Rationale:
Troponin is the most specific biomarker for myocardial injury. A normal troponin level is <0.04 ng/mL, and levels increase after myocardial damage.
A troponin of 1.2 ng/mL indicates myocardial injury consistent with MI. Blood pressure and respiratory rate do not confirm myocardial damage, and 0.02 ng/mL is still within the normal range.

A patient is diagnosed with an acute myocardial infarction. Which medication combination is commonly administered initially to manage symptoms and reduce cardiac workload?

A. Insulin, heparin, potassium
B. Morphine, oxygen, nitrates, aspirin
C. Furosemide, digoxin, warfarin
D. Epinephrine, atropine, dopamine

Correct Answer: B

Rationale:
Initial treatment of MI often follows the MONA protocol:

• M – Morphine (pain relief and decreased cardiac workload)

• O – Oxygen (improves oxygen supply)

• N – Nitrates (dilates coronary arteries)

• A – Aspirin (reduces platelet aggregation and clot formation)

  Sp26 Chapter 23, 24 - Perfusion…

These interventions improve myocardial oxygenation and limit infarct size.

A nurse is caring for a patient suspected of having an acute myocardial infarction. Which action should the nurse perform first?

A. Obtain a 12-lead ECG
B. Encourage the patient to ambulate
C. Provide a high-protein meal
D. Restrict oxygen therapy

Correct Answer: A

Rationale:
A 12-lead ECG is essential for identifying the presence and type of myocardial infarction (such as STEMI or NSTEMI). Early ECG assessment allows rapid diagnosis and initiation of appropriate treatment.

Sp26 Chapter 23, 24 - Perfusion…

Ambulation and meals are inappropriate during acute MI. Oxygen may be administered if needed rather than restricted.

A patient presents to the emergency department with chest pain that began 2 hours ago while walking. The patient describes the pain as “crushing,” radiating to the left arm, and not relieved by rest. The nurse suspects myocardial infarction. Which additional finding would most strongly support this suspicion?

A. Blood glucose of 140 mg/dL
B. Diaphoresis and nausea
C. Heart rate of 88 bpm
D. Respiratory rate of 18/min

Correct Answer: B

Rationale:
Classic manifestations of myocardial infarction include crushing chest pain, radiation to the left arm or jaw, diaphoresis, nausea/vomiting, tachycardia, shortness of breath, anxiety, and cool clammy skin.

Sp26 Chapter 23, 24 - Perfusion…

Diaphoresis and nausea are common autonomic responses to myocardial ischemia and strongly support the diagnosis of MI. The other findings are nonspecific and may occur in many conditions.

A nurse is caring for a patient diagnosed with an acute myocardial infarction. Which assessment finding requires the most immediate intervention?

A. Mild anxiety and restlessness
B. Heart rate of 102 bpm
C. Increasing shortness of breath and cool clammy skin
D. Pain rating of 4/10

Correct Answer: C

Rationale:
Shortness of breath combined with cool clammy skin suggests poor tissue perfusion and worsening cardiac output, which can occur during an MI.

Sp26 Chapter 23, 24 - Perfusion…

These findings may indicate deterioration such as cardiogenic shock or worsening ischemia. Anxiety, mild tachycardia, and moderate pain are common with MI but are less immediately life-threatening.

A patient diagnosed with myocardial infarction receives medications but continues to have severe chest pain and ECG changes. Which intervention should the nurse anticipate next?

A. Percutaneous coronary intervention (PCI)
B. Fluid restriction
C. Bedrest for 24 hours only
D. Administration of oral antihypertensives

Correct Answer: A

Rationale:
If medications do not restore adequate blood flow during myocardial infarction, patients may require invasive interventions such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) to reopen blocked coronary arteries.

Sp26 Chapter 23, 24 - Perfusion…

PCI uses balloon angioplasty and stent placement to restore coronary blood flow and limit myocardial damage. Fluid restriction and oral antihypertensives do not treat coronary artery occlusion.

A patient is 2 hours post–percutaneous coronary intervention (PCI) via the femoral artery. Which assessment finding requires the most immediate intervention?

A. Blood pressure 112/70 mmHg
B. Mild soreness at the insertion site
C. Cool, pale foot with absent pedal pulse on the affected leg
D. Heart rate 88 bpm

Correct Answer: C

Rationale:
After PCI, the nurse must perform frequent perfusion assessments of the affected limb, especially when the femoral artery is used. Signs such as a cool, pale extremity and absent pulse indicate arterial occlusion or impaired circulation, which is a serious complication requiring immediate provider notification.

Sp26 Chapter 23, 24 - Perfusion…

Normal blood pressure, mild soreness at the site, and a heart rate of 88 bpm are expected findings after PCI and do not indicate a life-threatening complication.

A nurse is caring for a patient who had PCI performed through the femoral artery. Which nursing intervention is most important to prevent bleeding complications?

A. Encourage the patient to ambulate immediately
B. Keep the affected leg straight for several hours
C. Elevate the head of the bed to 90°
D. Apply warm compresses to the insertion site

Correct Answer: B

Rationale:
After PCI via the femoral artery, patients must remain on bedrest with the affected leg straight for several hours to prevent bleeding and hematoma formation at the arterial access site.

Sp26 Chapter 23, 24 - Perfusion…

Early ambulation can cause arterial bleeding. Excessive elevation of the head of the bed may increase pressure at the insertion site. Warm compresses are not standard management and could worsen bleeding.

A patient is discharged after PCI with a coronary stent. Which medication is most important to prevent stent thrombosis?

A. Acetaminophen
B. Clopidogrel
C. Furosemide
D. Insulin

Correct Answer: B

Rationale:
After PCI with stent placement, patients are typically prescribed antiplatelet medications such as aspirin or clopidogrel to prevent clot formation within the stent.

Sp26 Chapter 23, 24 - Perfusion…

Clopidogrel inhibits platelet aggregation and reduces the risk of stent thrombosis, which can lead to another myocardial infarction. Acetaminophen treats pain, furosemide is a diuretic, and insulin manages blood glucose but do not prevent stent thrombosis.

A patient is 4 hours post–PCI via the femoral artery. The nurse notes the patient reports severe back pain, hypotension, and increasing abdominal distention. What complication should the nurse suspect?

A. Cardiac tamponade
B. Retroperitoneal bleeding
C. Pulmonary embolism
D. Acute myocardial infarction

Correct Answer: B

Rationale:
One of the serious complications after PCI, particularly with femoral access, is retroperitoneal bleeding. Signs may include severe back or abdominal pain, hypotension, abdominal distention, and signs of internal bleeding.
This occurs when bleeding extends into the retroperitoneal space and may not be immediately visible externally. Cardiac tamponade involves fluid accumulation around the heart, pulmonary embolism presents with sudden respiratory distress, and MI would typically present with chest pain and ECG changes.

A patient who underwent PCI earlier in the day has the following findings: decreased urine output, rising creatinine levels, and fatigue. Which complication should the nurse suspect?

A. Cardiogenic shock
B. Contrast-induced acute kidney injury
C. Pulmonary edema
D. Acute myocardial infarction

Correct Answer: B

Rationale:
During PCI, contrast dye is used to visualize coronary arteries. One potential complication is contrast-induced acute kidney injury (AKI), particularly in patients with preexisting kidney disease or diabetes.

Sp26 Chapter 23, 24 - Perfusion…

Signs include decreased urine output and rising creatinine levels. Monitoring intake and output and encouraging hydration are important post-procedure nursing interventions to reduce this risk. Cardiogenic shock and pulmonary edema present with different cardiovascular or respiratory symptoms

A patient is 4 hours post–CABG surgery in the ICU. Which assessment finding requires the most immediate intervention?

A. Chest tube drainage of 40 mL/hr of dark red blood
B. Heart rate of 96 bpm
C. Chest tube drainage of 220 mL in one hour
D. Oxygen saturation of 96%

Correct Answer: C

Rationale:
After CABG surgery, nurses must closely monitor chest tube output because excessive bleeding is a major postoperative complication. Chest tubes remove blood and fluid from the mediastinal space, and large amounts of drainage may indicate postoperative hemorrhage.

Sp26 Chapter 23, 24 - Perfusion…

Drainage of 220 mL in one hour is abnormal and requires immediate provider notification. Drainage of 40 mL/hr is generally expected early after surgery. A heart rate of 96 bpm and oxygen saturation of 96% are within acceptable ranges for a postoperative patient.

A nurse is caring for a patient recovering from CABG surgery. Which nursing intervention is most important for preventing postoperative pulmonary complications?

A. Encourage deep breathing and coughing exercises
B. Restrict fluid intake
C. Maintain strict bedrest for 48 hours
D. Avoid incentive spirometry

Correct Answer: A

Rationale:
Pulmonary complications are common after CABG because patients may have decreased lung expansion due to anesthesia, pain, and immobility. Nursing care focuses on deep breathing, coughing exercises, and use of incentive spirometry to improve lung expansion and prevent complications such as atelectasis or pneumonia.

Sp26 Chapter 23, 24 - Perfusion…

Bedrest for prolonged periods increases pulmonary risks. Incentive spirometry should be encouraged, not avoided.

A patient is 12 hours post–CABG surgery. The nurse notes the following findings: hypotension, jugular venous distention, and decreasing chest tube drainage. Which complication should the nurse suspect?

A. Pulmonary embolism
B. Cardiac tamponade
C. Hypovolemic shock
D. Atelectasis

Correct Answer: B

Rationale:
Cardiac tamponade is a life-threatening complication after CABG caused by fluid or blood accumulating around the heart, which compresses the heart and prevents proper filling. Key signs include hypotension, jugular venous distention, and decreased chest tube output, indicating blood may be collecting around the heart instead of draining through the tubes.

Sp26 Chapter 23, 24 - Perfusion…

Pulmonary embolism usually presents with sudden respiratory distress. Hypovolemic shock would present with increased chest tube drainage rather than decreased drainage. Atelectasis causes respiratory symptoms but not JVD.

A nurse is assessing the leg of a patient who had a saphenous vein graft harvested for CABG. Which finding requires immediate provider notification?

A. Mild swelling at the incision site
B. Leg warm with palpable pulses
C. Pale leg with weak pedal pulse and delayed capillary refill
D. Slight bruising around the incision

Correct Answer: C

Rationale:
During CABG, the saphenous vein is commonly harvested from the leg for grafting. After surgery, the nurse must monitor the extremity for adequate perfusion, including color, temperature, capillary refill, and pulses.

Sp26 Chapter 23, 24 - Perfusion…

A pale extremity with weak pulse and delayed capillary refill indicates impaired circulation, which may lead to ischemia if not treated. Mild swelling or bruising is expected after surgery, and a warm leg with palpable pulses indicates adequate circulation.

A nurse is caring for a patient the day after CABG surgery. The patient refuses to use the incentive spirometer due to pain. What is the best nursing action?

A. Document the refusal and continue with other care
B. Administer prescribed pain medication and encourage spirometry afterward
C. Restrict oral fluids
D. Maintain strict bedrest for the remainder of the day

Correct Answer: B

Rationale:
Pulmonary complications such as atelectasis and pneumonia are common after CABG surgery due to anesthesia, immobility, and shallow breathing from pain. Nurses must encourage deep breathing, coughing, and use of incentive spirometry to promote lung expansion.

Sp26 Chapter 23, 24 - Perfusion…

If pain is preventing participation, the nurse should administer pain medication first, then encourage the patient to perform breathing exercises. Ignoring the refusal increases the risk of respiratory complications, and bedrest or fluid restriction does not address lung expansion.

A patient who underwent CABG surgery 10 hours ago develops sudden hypotension. The nurse notes jugular venous distention and decreasing chest tube drainage over the last hour. Which complication should the nurse suspect?

A. Pulmonary embolism
B. Cardiac tamponade
C. Hypovolemic shock
D. Atelectasis

Correct Answer: B

Rationale:
Cardiac tamponade occurs when blood or fluid accumulates in the pericardial sac, compressing the heart and preventing proper ventricular filling.

Sp26 Chapter 23, 24 - Perfusion…

After CABG surgery, tamponade may occur when blood collects around the heart instead of draining through chest tubes. Classic signs include hypotension, jugular venous distention, and muffled heart sounds, along with decreasing chest tube output. Pulmonary embolism and atelectasis primarily cause respiratory symptoms, and hypovolemic shock typically presents with increased bleeding rather than decreased chest tube output.

A nurse is reviewing the pathophysiology of cardiac tamponade. Which physiologic change is responsible for the decreased cardiac output seen in this condition?

A. Increased myocardial contractility
B. Compression of the heart preventing ventricular filling
C. Decreased systemic vascular resistance
D. Increased pulmonary vascular resistance

Correct Answer: B

Rationale:
In cardiac tamponade, fluid accumulates in the pericardial space, creating pressure that compresses the heart and prevents the ventricles from filling during diastole. This leads to decreased stroke volume and decreased cardiac output, resulting in hypotension and poor tissue perfusion.

Sp26 Chapter 23, 24 - Perfusion…

Increased contractility would increase cardiac output rather than decrease it, and vascular resistance changes are not the primary cause of tamponade.

A patient with suspected cardiac tamponade becomes increasingly hypotensive and dyspneic. Which intervention should the nurse anticipate as the definitive treatment?

A. Administration of diuretics
B. Pericardiocentesis
C. IV insulin therapy
D. Endotracheal intubation

Correct Answer: B

Rationale:
The definitive treatment for cardiac tamponade is pericardiocentesis, a procedure in which a needle is inserted into the pericardial sac to remove accumulated fluid and relieve pressure on the heart.

Sp26 Chapter 23, 24 - Perfusion…

Removing the fluid allows the ventricles to fill normally and restores cardiac output. Diuretics do not rapidly relieve tamponade, insulin is unrelated, and intubation may support breathing but does not address the underlying cause of decreased cardiac output.

A nurse is assessing a patient with suspected cardiac tamponade. Which combination of findings represents Beck’s triad, a classic indicator of cardiac tamponade?

A. Hypotension, jugular venous distention, muffled heart sounds
B. Hypertension, tachycardia, bounding pulses
C. Hypotension, crackles in lungs, fever
D. Bradycardia, warm skin, hypotension

Correct Answer: A

Rationale:
Beck’s triad is the classic set of findings associated with cardiac tamponade and includes:

• Hypotension (due to decreased cardiac output)

• Jugular venous distention (JVD) (due to impaired venous return)

• Muffled heart sounds (due to fluid surrounding the heart)

These findings occur because fluid accumulation in the pericardial sac compresses the heart and prevents proper ventricular filling.

A nurse is caring for a patient with cardiac tamponade. Which hemodynamic change would the nurse expect due to impaired ventricular filling?

A. Increased cardiac output
B. Increased systemic perfusion
C. Decreased stroke volume and cardiac output
D. Increased stroke volume

Correct Answer: C

Rationale

In cardiac tamponade, fluid accumulates within the pericardial sac, causing compression of the heart.

This compression prevents the ventricles from filling properly during diastole, which leads to:

• Reduced stroke volume

• Decreased cardiac output

• Hypotension

• Poor tissue perfusion

Because the heart cannot fill normally, it cannot pump enough blood to maintain circulation, leading to signs of shock.

A nurse is assessing a patient with heart failure. Which finding is most consistent with left-sided heart failure?

A. Peripheral edema and ascites
B. Jugular venous distention
C. Pulmonary crackles and dyspnea
D. Hepatomegaly

Correct Answer: C

Rationale:
Left-sided heart failure occurs when the left ventricle cannot pump effectively, causing blood to back up into the pulmonary circulation. This leads to symptoms such as dyspnea, pulmonary crackles, orthopnea, and paroxysmal nocturnal dyspnea.

Sp26 Chapter 23, 24 - Perfusion…

Peripheral edema, hepatomegaly, and jugular venous distention are more commonly associated with right-sided heart failure, where blood backs up into the systemic circulation.

A patient with heart failure is being monitored for fluid retention. Which assessment finding best indicates worsening fluid overload?

A. Heart rate 88 bpm
B. Weight gain of 3 pounds in 24 hours
C. Respiratory rate 18/min
D. Blood pressure 124/78 mmHg

Correct Answer: B

Rationale:
Daily weight is the most sensitive indicator of fluid retention in patients with heart failure.

Sp26 Chapter 23, 24 - Perfusion…

A weight gain of 3 pounds in 24 hours suggests significant fluid accumulation and worsening heart failure. Changes in heart rate, respiratory rate, or blood pressure may occur but are not as sensitive for detecting fluid overload.

A patient with heart failure is prescribed furosemide (Lasix). What is the primary purpose of this medication?

A. Increase heart rate
B. Reduce fluid overload
C. Increase blood clotting
D. Improve oxygen saturation

Correct Answer: B

Rationale:
Furosemide is a loop diuretic used to treat heart failure by promoting the excretion of sodium and water through the kidneys. This helps reduce fluid overload, decrease edema, and relieve pulmonary congestion.

Sp26 Chapter 23, 24 - Perfusion…

The medication does not directly increase heart rate, affect clotting, or increase oxygen saturation

A nurse is reviewing a patient’s echocardiogram results. The provider explains that the patient’s mitral valve does not close properly and allows blood to flow backward into the left atrium during ventricular contraction. How should the nurse interpret this condition?

A. Mitral stenosis
B. Mitral regurgitation
C. Aortic stenosis
D. Tricuspid stenosis

Correct Answer: B

Rationale:
Valve regurgitation occurs when a heart valve fails to close properly, allowing blood to flow backward into the previous chamber. Mitral Regurgitation This leads to decreased forward cardiac output and increased workload on the heart. In contrast, stenosis refers to a valve that does not open completely, restricting forward blood flow.

A patient who recently received a mechanical heart valve replacement asks why they must take anticoagulant medication for the rest of their life. What is the nurse’s best response?

A. Mechanical valves cause infection
B. Mechanical valves decrease cardiac output
C. Mechanical valves increase the risk of blood clot formation
D. Mechanical valves increase blood pressure

Correct Answer: C

Rationale:
Patients with mechanical heart valves require lifelong anticoagulation because the artificial material increases the risk of thrombus formation on the valve surface, which can lead to embolic complications such as stroke. Mechanical Heart Valve Biologic valves made from animal or human tissue usually do not require lifelong anticoagulation but have a shorter lifespan.

Question 3 (Valve Disease Assessment)
A nurse is assessing a patient with suspected heart valve disease. Which finding would most strongly suggest a valvular disorder?

A. Heart murmur on auscultation
B. Blood pressure 128/82 mmHg
C. Respiratory rate 18/min
D. Temperature 37°C (98.6°F)

Correct Answer: A

Rationale:
A heart murmur is a key clinical sign of valvular disease because abnormal blood flow across a stenotic or regurgitant valve produces turbulent blood flow that can be heard during auscultation. Heart Valve Disease Normal vital signs such as blood pressure, respiratory rate, and temperature do not specifically indicate valve dysfunction.

A patient with a mechanical heart valve replacement is admitted with sudden weakness on the right side of the body and difficulty speaking. Which complication should the nurse suspect?

A. Pulmonary infection
B. Hypovolemia
C. Thromboembolism
D. Heart failure.

Correct Answer: C

Rationale:
Mechanical heart valves increase the risk of thrombus formation, which can break loose and cause thromboembolic events such as stroke. Mechanical Heart Valve
For this reason, patients with mechanical valves require lifelong anticoagulation therapy. Sudden neurological symptoms such as weakness and speech difficulty suggest a possible embolic stroke. Heart failure and infection would present with different symptoms

A patient is diagnosed with aortic stenosis. Which pathophysiologic change occurs as a result of this condition?

A. Blood flow into the pulmonary arteries decreases
B. Blood flows backward into the left atrium
C. Blood flow from the right atrium to the right ventricle is obstructed
D. Blood flow from the left ventricle to the aorta becomes restricted

Correct Answer: D

Rationale:
Aortic stenosis occurs when the aortic valve does not open completely, restricting blood flow from the left ventricle into the aorta. Aortic Stenosis
This causes increased pressure in the left ventricle, forcing the heart to work harder to pump blood through the narrowed valve. Option A describes mitral regurgitation, not aortic stenosis.

A nurse is caring for a patient who recently underwent heart valve replacement surgery. Which assessment finding requires immediate intervention?

A. Blood pressure 124/76 mmHg
B. Heart rate 84 bpm
C. New onset irregular heart rhythm
D. Temperature 36.9°C (98.4°F)

Correct Answer: C

Rationale:
After valve surgery, patients are at risk for dysrhythmias, which can decrease cardiac output and lead to hemodynamic instability. Heart Valve Disease
A new onset irregular heart rhythm should be evaluated immediately because it may indicate atrial fibrillation or other arrhythmias. Normal heart rate, temperature, and blood pressure do not indicate immediate complications.

A patient is diagnosed with mitral regurgitation. Which hemodynamic change would the nurse expect with this condition?

A. Blood flows backward from the left ventricle into the left atrium during systole
B. Blood cannot move from the right atrium to the right ventricle
C. Blood flow from the left ventricle into the aorta becomes obstructed
D. Blood flows backward from the pulmonary artery into the right ventricle

Correct Answer: A

Rationale:
In mitral regurgitation, the mitral valve does not close properly, allowing blood to flow backward from the left ventricle into the left atrium during systole. Mitral Regurgitation
This decreases forward cardiac output and increases pressure in the left atrium and pulmonary circulation. Options B and D describe different valve problems, and option C describes aortic stenosis.

A patient with a mechanical heart valve asks the nurse why they must take anticoagulants every day. Which explanation is most accurate?

A. The medication prevents infection of the valve
B. The medication helps the valve open and close normally
C. The medication prevents blood clots from forming on the artificial valve
D. The medication increases cardiac output

Correct Answer: C

Rationale:
Artificial materials used in mechanical valves increase the risk of blood clot formation. Anticoagulant therapy is required to prevent thrombus formation on the valve surface, which could lead to stroke or systemic embolism. Mechanical Heart Valve
Anticoagulants do not prevent infection or increase cardiac output.

A nurse is caring for a patient with severe aortic stenosis. Which symptom should the nurse recognize as a classic manifestation of this condition?

A. Chest pain and syncope during exertion
B. Severe peripheral edema
C. Productive cough with sputum
D. Sudden weight loss

Correct Answer: A

Rationale:
A classic symptom pattern of aortic stenosis includes chest pain, syncope, and dyspnea, especially during physical exertion. Aortic Stenosis
These symptoms occur because the narrowed valve restricts blood flow from the left ventricle into the aorta, reducing systemic perfusion during activity. Peripheral edema is more associated with right-sided heart failure.

A patient with mitral valve regurgitation is being assessed by the nurse. Which clinical manifestation is most likely associated with this condition?

A. Backflow of blood into the left atrium
B. Obstruction of blood flow into the pulmonary artery
C. Decreased blood flow from the right atrium to the right ventricle
D. Complete blockage of blood flow into the aorta

Correct Answer: A

Rationale:
In mitral regurgitation, the mitral valve does not close properly, allowing blood to flow backward from the left ventricle into the left atrium during systole. Mitral Regurgitation
This decreases forward cardiac output and increases pressure in the left atrium and pulmonary circulation, which can lead to dyspnea and fatigue

A patient is diagnosed with mitral stenosis. Which hemodynamic change would the nurse expect with this condition?

A. Blood flows backward from the left ventricle into the left atrium
B. Blood flow from the left atrium into the left ventricle becomes restricted
C. Blood flow from the right ventricle into the pulmonary artery is blocked
D. Blood flows backward from the aorta into the left ventricle

Correct Answer: B

Rationale:
In mitral stenosis, the mitral valve opening becomes narrowed, preventing blood from flowing normally from the left atrium into the left ventricle. Heart Valve Disease
This leads to increased pressure in the left atrium and pulmonary circulation, which may result in shortness of breath and pulmonary congestion. Backward blood flow would indicate regurgitation rather than stenosis.

A nurse is assessing a patient with aortic regurgitation. Which finding would the nurse most likely expect?

A. Backflow of blood from the aorta into the left ventricle
B. Restricted blood flow from the left ventricle into the aorta
C. Obstruction of blood flow from the right atrium into the right ventricle
D. Decreased blood flow from the pulmonary artery to the lungs

Correct Answer: A

Rationale:
In aortic regurgitation, the aortic valve does not close properly, allowing blood to flow backward from the aorta into the left ventricle during diastole. Heart Valve Disease
This increases the workload on the left ventricle and can lead to ventricular enlargement and decreased cardiac efficiency over time.

A nurse auscultates a new heart murmur while assessing a patient with suspected valve disease. What is the most likely cause of this murmur?

A. Increased blood pressure in the arteries
B. Turbulent blood flow across a damaged or narrowed valve
C. Increased oxygen levels in the blood
D. Decreased respiratory rate

Correct Answer: B

Rationale:
Heart murmurs occur when blood flows turbulently across abnormal heart valves, such as those affected by stenosis or regurgitation. Heart Valve Disease
In stenosis, turbulence occurs because blood is forced through a narrowed opening, while in regurgitation, turbulence occurs due to backward blood flow.

Key Exam Concepts

Dilated cardiomyopathy
→ enlarged weak heart
→ systolic dysfunction

Hypertrophic cardiomyopathy
→ thick heart muscle
→ risk of sudden cardiac death

Restrictive cardiomyopathy
→ stiff heart
→ filling problem

Key Exam Concepts

Dilated cardiomyopathy
→ enlarged weak heart
→ systolic dysfunction

Hypertrophic cardiomyopathy
→ thick heart muscle
→ risk of sudden cardiac death

Restrictive cardiomyopathy
→ stiff heart
→ filling problem

A nurse reviews an echocardiogram report showing enlarged ventricles with thin, weakened heart muscle and decreased pumping ability. Which type of cardiomyopathy does this finding indicate?

A. Hypertrophic cardiomyopathy
B. Dilated cardiomyopathy
C. Restrictive cardiomyopathy
D. Obstructive cardiomyopathy

Correct Answer: B

Rationale:
In dilated cardiomyopathy, the ventricles become enlarged and weakened, resulting in decreased contractility and reduced cardiac output. This often leads to heart failure symptoms such as dyspnea, fatigue, and edema. The heart muscle becomes thin and stretched, reducing its ability to pump effectively.

A nurse is assessing a young athlete who suddenly collapses during practice. Which cardiomyopathy is most commonly associated with sudden cardiac death in young athletes?

A. Dilated cardiomyopathy
B. Restrictive cardiomyopathy
C. Hypertrophic cardiomyopathy
D. Ischemic cardiomyopathy

Correct Answer: C

Rationale:
Hypertrophic cardiomyopathy involves abnormal thickening of the heart muscle, particularly the ventricular septum. This thickening can obstruct blood flow and disrupt electrical conduction, increasing the risk of fatal dysrhythmias and sudden cardiac death, especially during strenuous activity.

A patient is diagnosed with restrictive cardiomyopathy. Which hemodynamic problem should the nurse expect with this condition?

A. The ventricles cannot contract effectively
B. The ventricles cannot relax and fill properly
C. Blood cannot leave the left ventricle
D. Blood flows backward through the mitral valve

Correct Answer: B

Rationale:
In restrictive cardiomyopathy, the heart muscle becomes stiff and noncompliant, which prevents the ventricles from relaxing and filling normally during diastole. This results in reduced ventricular filling and decreased cardiac output, leading to symptoms such as fatigue, dyspnea, and edema.

A nurse is assessing a patient with dilated cardiomyopathy. Which finding is most consistent with this condition?

A. Thickened ventricular walls and decreased chamber size
B. Enlarged ventricles with decreased contractility
C. Normal ventricular size with impaired valve closure
D. Narrowed coronary arteries causing ischemia

Correct Answer: B

Rationale:
In dilated cardiomyopathy, the ventricles become enlarged and weakened, which leads to decreased myocardial contractility and reduced cardiac output. This causes symptoms similar to heart failure such as fatigue, dyspnea, and peripheral edema. Hypertrophic cardiomyopathy causes thickened ventricular walls, not enlarged chambers.

A nurse is caring for a patient with hypertrophic cardiomyopathy. Which complication is the nurse most concerned about?

A. Acute kidney injury
B. Sudden cardiac death due to dysrhythmias
C. Severe dehydration
D. Pulmonary embolism

Correct Answer: B

Rationale:
Hypertrophic cardiomyopathy is associated with abnormal thickening of the heart muscle, which can disrupt electrical conduction in the heart. This increases the risk of life-threatening dysrhythmias and sudden cardiac death, particularly in young individuals and athletes.

A patient with cardiomyopathy reports shortness of breath, fatigue, and swelling of the legs. What is the nurse’s best interpretation of these symptoms?

A. Signs of decreased cardiac output and heart failure
B. Evidence of acute respiratory infection
C. Indication of valve stenosis
D. Normal findings with cardiomyopathy

Correct Answer: A

Rationale:
Cardiomyopathies weaken or stiffen the heart muscle, impairing its ability to pump blood effectively. This leads to reduced cardiac output and symptoms of heart failure, including fatigue, dyspnea, and peripheral edema due to fluid accumulation. These symptoms require monitoring and treatment to prevent worsening heart failure.

Key Exam Clues

Endocarditis
→ heart valve infection
→ fever + murmur + IV antibiotics

Myocarditis
→ heart muscle inflammation
→ dysrhythmias + heart failure symptoms

Pericarditis
→ pericardial inflammation
→ sharp chest pain relieved by leaning forward

Key Exam Clues

Endocarditis
→ heart valve infection
→ fever + murmur + IV antibiotics

Myocarditis
→ heart muscle inflammation
→ dysrhythmias + heart failure symptoms

Pericarditis
→ pericardial inflammation
→ sharp chest pain relieved by leaning forward

A patient with a history of IV drug use presents with fever, fatigue, and a new heart murmur. Which cardiac infection should the nurse most strongly suspect?

A. Myocarditis
B. Pericarditis
C. Endocarditis
D. Cardiomyopathy

Rationale: Correct Answer: C
Endocarditis
Endocarditis is an infection of the endocardium and heart valves, most commonly caused by bacteria entering the bloodstream. Risk factors include IV drug use, prosthetic valves, congenital heart disease, and dental infections. A new heart murmur combined with fever is a classic sign because infection damages the valve and disrupts blood flow.

A patient reports sharp chest pain that worsens with deep breathing and improves when sitting up and leaning forward. Which condition does the nurse suspect?

A. Myocarditis
B. Pericarditis
C. Aortic stenosis
D. Dilated cardiomyopathy

Correct Answer: B

Rationale:
Pericarditis
Pericarditis is inflammation of the pericardium, the sac surrounding the heart. A classic finding is sharp chest pain that worsens with inspiration and improves when leaning forward. This occurs because changing position decreases pressure on the inflamed pericardium.

A patient diagnosed with viral myocarditis begins to develop fatigue, dyspnea, and irregular heart rhythms. What is the underlying cause of these symptoms?

A. Narrowing of the coronary arteries
B. Inflammation and damage to the heart muscle
C. Obstruction of blood flow through the aortic valve
D. Accumulation of fluid in the pericardial sac

Correct Answer: B

Rationale:
Myocarditis
Myocarditis involves inflammation of the myocardium, which weakens the heart muscle and reduces its ability to pump effectively. This can lead to heart failure symptoms, dysrhythmias, and decreased cardiac output. Viral infections are the most common cause.

A nurse auscultates a scratchy, grating sound over the patient’s heart during assessment. Which condition is most likely causing this finding?

A. Cardiomyopathy
B. Myocardial infarction
C. Pericarditis
D. Dilated cardiomyopathy

Correct Answer: C

Rationale:
Pericarditis
A pericardial friction rub is a characteristic sound heard in patients with pericarditis. It occurs when the inflamed layers of the pericardium rub against each other during the cardiac cycle, producing a scratchy or grating sound heard with a stethoscope.

A patient arrives in the emergency department with sudden chest pain and shortness of breath. Which diagnostic test should the nurse anticipate first to determine if the patient is having a myocardial infarction?

A. Echocardiogram
B. 12-lead ECG
C. Chest CT scan
D. Cardiac MRI

Correct Answer: B

Rationale:
A 12-lead ECG is the first diagnostic test performed when a myocardial infarction is suspected because it rapidly identifies ischemia, infarction, and dysrhythmias. It can show ST elevation or depression, which helps determine the type of myocardial infarction (STEMI vs NSTEMI). Echocardiography and MRI provide structural information but are not the immediate test used for rapid diagnosis.

A nurse reviews laboratory results for a patient with suspected myocardial infarction. Which finding most strongly indicates myocardial injury?

A. Troponin 1.5 ng/mL
B. Troponin 0.02 ng/mL
C. Potassium 4.0 mEq/L
D. Sodium 138 mEq/L

Correct Answer: A

Rationale:
Troponin is the most specific biomarker for myocardial injury. Normal troponin levels are less than 0.04 ng/mL. A level of 1.5 ng/mL indicates damage to the heart muscle consistent with myocardial infarction. Electrolytes such as potassium and sodium are important but do not directly indicate myocardial injury.

A nurse is reviewing the results of a patient’s echocardiogram, which shows an ejection fraction (EF) of 30%. How should the nurse interpret this finding?

A. Normal cardiac function
B. Severe hypertension
C. Decreased ventricular pumping ability
D. Increased cardiac output

Correct Answer: C

Rationale:
An echocardiogram evaluates heart structure and function, including ejection fraction (EF). Normal EF is approximately 55–70%. An EF of 30% indicates reduced ventricular contractility, which is commonly seen in heart failure or cardiomyopathy. A decreased EF means the heart is not pumping enough blood with each contraction.

Q10. A 55-year-old male presents to the emergency department reporting "crushing" chest pain that radiates to his left arm. The nurse notes the patient is diaphoretic and the pain is not relieved by rest. Which type of acute coronary syndrome is characterized by severe occlusion and results in necrosis, but does NOT show ST-segment elevation on a 12-lead EKG?

Unstable Angina

ST-segment elevation MI (STEMI)

Non-ST elevation MI (NSTEMI)

Stable Angina

Correct Answer: Non-ST elevation MI (NSTEMI)

• 
  

  Detailed Rationale: According to the "EKG Interpretation for Acute MI" chart, an NSTEMI involves severe occlusion and results in necrosis. Unlike a STEMI, which shows ST elevation and complete occlusion, an NSTEMI does not show ST-segment elevation. Unstable angina involves minimal occlusion and results in no necrosis.

A client is admitted with Right-Sided Heart Failure. Which clinical manifestation should the nurse expect to find during the admission physical assessment?

• Crackles and wheezes upon lung auscultation

  
  

• Pink-tinged, frothy sputum

  
  

• Jugular Venous Distension (JVD) and peripheral edema

  
  

• Orthopnea and paroxysmal nocturnal dyspnea

  
  

Correct Answer: Jugular Venous Distension (JVD) and peripheral edema

• 
  

  Detailed Rationale: According to the clinical manifestations of heart failure, Right-Sided HF is characterized by systemic congestion, including JVD, peripheral edema, weight gain, and an enlarged liver/spleen. Crackles, frothy sputum, and orthopnea are classic signs of Left-Sided HF, which involves pulmonary edema and congestion.

The nurse is caring for a client with Heart Failure who has an ordered dose of Digoxin. Which statement correctly describes the primary action of this medication in improving cardiac output?

It reduces preload by promoting the excretion of sodium and water

It decreases afterload by dilating peripheral blood vessels

It increases contractility while slowing the heart rate

It prevents the conversion of Angiotensin I to Angiotensin II

Correct Answer: It increases contractility while slowing the heart rate

Detailed Rationale: The document identifies Digoxin as a positive inotrope that increases contractility by increasing calcium and slows the heart rate. Diuretics reduce preload , ACE inhibitors/ARBS reduce afterload by dilating vessels , and ACE inhibitors specifically block the formation of Angiotensin II

A client is diagnosed with Aortic Stenosis. Which triad of symptoms should the nurse monitor for most closely, as they represent the most concerning manifestations of this valve disease?

• Hemoptysis, cough, and atrial fibrillation

  
  

• Angina, syncope, and dyspnea on exertion

  
  

• Bounding pulses, widened pulse pressure, and diastolic murmur

  
  

• Fatigue, palpitations, and systolic murmur

  
  

Correct Answer: Angina, syncope, and dyspnea on exertion

• 
  

  Detailed Rationale: The "Valve Disease Clinical Manifestations" chart specifically links Aortic Stenosis to angina, syncope, and dyspnea on exertion, often accompanied by a harsh systolic murmur. Hemoptysis and AFib are associated with Mitral Stenosis , while bounding pulses and widened pulse pressure are characteristic of Aortic Regurgitation.

The nurse is auscultating the heart sounds of a client with suspected valve disease. The nurse identifies a murmur that occurs when the valve does not close completely, allowing blood to flow backward. How should the nurse document this specific pathophysiology?

Stenosis

Prolapse

Regurgitation

Infarction

Correct Answer: Regurgitation

• 
  

  Detailed Rationale: Regurgitation, also known as insufficiency, occurs when valves do not close completely and blood flows backward through the valve. Stenosis is a narrowing of the valve that restricts forward flow , and prolapse occurs when valve leaflets bulge back. Infarction refers to tissue necrosis due to a lack of blood flow and is not a descriptor of valve movement.