NURS 470 Final: Shock/MODS

All forms of shock have which characteristic in common?

Inadequate circulating fluid levels

Loss of sympathetic nervous system innervation

Tissue oxygen supply in excess of oxygen demand

Imbalance between tissue oxygen supply and oxygen demand

D

When shock develops, the body attempts to meet the crisis through which mechanism?

Releasing cortisol, norepinephrine, and epinephrine

Activating the parasympathetic nervous system

Decreasing venous return to the right heart

Inhibiting the release of aldosterone

A

Angiotensin II plays an important role in increasing blood pressure through which action?

Decreasing afterload

Blocking aldosterone release

Vasoconstriction

Stimulating secretion of renin

C

How is the compensatory stage of shock best characterized?

Anaerobic metabolism and lactic acidosis begin.

Neuroendocrine responses are activated.

Organ function becomes compromised.

The client becomes resistant to treatment.

B

Which two underlying shock-related factors cause the majority of clinical manifestations associated with shock?

Fluid deficiencies and electrolyte imbalances

Activation of compensatory mechanisms and inadequate oxygen delivery

Impaired alveolar oxygenation and increased cardiac output

Loss of organ function and decreased oxygen carrying capacity of the blood

B

Which statement best describes the use of traditional parameters (e.g., blood pressure, heart rate, and appearance) to assess a client for the presence of shock?

They accurately reflect a shock state.

They are of little use in the assessment of shock states.

They provide supportive data but cannot be relied on.

They can be used for diagnosis of some shock states but not others.

C

In the assessment of shock, arterial pH can be measured in conjunction with which two parameters to evaluate the client's acid-base status?

Serum lactate and base excess/deficit

Pulse oximetry and blood pressure

Gastric tonometry and gastric pH

Venous oxygen saturation and pulmonary artery wedge pressure

A

A client's lactate level is 5.3 mmol/L. What would this value indicate to the nurse?

The client's arterial pH is likely to be alkalotic.

The client is receiving oxygen therapy at too high a concentration.

The client is likely to be experiencing tissue hyperperfusion.

The client is experiencing significant anaerobic metabolism.

D

Which therapy would most effectively increase the cardiac output component of a client's oxygen delivery?

O2 therapy by nasal cannula

Normal saline at 200 mL/hr

Low-dose dopamine

Acetaminophen

B

Why is it important to closely monitor the oxygen concentration being delivered to a client in shock?

High oxygen concentrations can impair the immune system.

High oxygen concentrations can reduce venous return to the heart.

High oxygen concentration decreases creatinine clearance by the kidney.

High oxygen concentration can result in tissue hypoxia.

A

Why would the nurse be alert for shivering in a client who is receiving physical cooling measures?

Shivering indicates cooling has reached its maximum effectiveness.

Once shivering begins, cooling measures should be discontinued.

Shivering increases metabolism and oxygen consumption.

The onset of shivering indicates hypothermia is reversing.

C

A client in septic shock has an NMBA initiated. Which other drug is most likely to be administered in conjunction with the NMBA?

Propofol

Lorazepam

Diazepam

Norepinephrine

A

In the treatment of shock, it is recommended that vasoactive drug therapy be considered at what point relative to fluid resuscitation?

At the same time as fluid resuscitation

As soon as fluid resuscitation has been completed

Immediately, before starting fluid resuscitation initiatives

If fluid resuscitation fails to sufficiently improve perfusion

D

All vasopressor drugs have which action in common?

Vasodilation

Increase heart contractility

Vasoconstriction

Increase stroke volume

C

The nurse is titrating norepinephrine on a client for treatment of shock. The healthcare provider has just ordered that the drug be discontinued. How should the nurse comply with this order?

Stop the drip immediately.

Gradually decrease the rate of flow over time.

Increase the maintenance IV fluid rate prior to discontinuing.

Decrease the rate over a 1-hour period and discontinue.

D

The provider has just ordered dobutamine for a client in shock. The nurse is aware that this type of drug has which physiologic effect?

Vasodilation

Vasoconstriction

Increases contractility

Decreases pulmonary vascular resistance

B

Which condition characterizes cardiogenic shock?

Impaired cardiac contractility and cardiac output

Increasing stroke volume in the face of decreasing cardiac output

Increasing stroke volume in the face of increasing cardiac output

Hypovolemic shock as the result of a massive myocardial infarction

A

Which combination of assessments should alert the nurse that the client may be developing cardiogenic shock? (Select all that apply.)

Sustained systolic blood pressure (SBP) of less than 90 mmHg

Cardiac index (CI) of less than 2.2 L/min/m2

Pulmonary artery wedge pressure (PAWP) of less than 4 mmHg

Client report of continuing chest pain and dyspnea

Reduced mentation

A, B, D, E

Initial management of cardiogenic shock focuses on which goals? (Select all that apply.)

Reduce pulmonary edema.

Provide fluid resuscitation.

Control cardiac dysrhythmias.

Increase BP.

Increase cardiac output.

A, C, D, E

A client in cardiogenic shock is undergoing placement of a left ventricular assist device (LVAD). What is a major purpose of this procedure?

To control cardiac dysrhythmias

To decrease afterload

To increase oxygen demand

To rest the injured myocardium

D

Which clinical situation could result in a relative fluid volume deficit?

Ascites

Hemorrhage

Dehydration

Severe burns

A

Clinical manifestations of hypovolemic shock develop when the client has lost which percentage of fluid volume?

10%

15%

20%

25%

D

In clients experiencing hemorrhagic shock, blood or blood products are usually ordered to achieve a hemoglobin of which level?

6 to 8 g/dL

7 to 9 g/dL

8 to 10 g/dL

9 to 11 g/dL

B

For a client with ongoing severe hemorrhage, the fluid resuscitation goal is to achieve what systolic blood pressure?

80 mmHg

90 mmHg

100 mmHg

110 mmHg

B

The various forms of distributive shock have which characteristic in common?

Endothelial injury

Massive vasodilation

Constriction of vascular smooth muscle

Loss of sympathetic nervous system response

B

Which pathophysiologic events are characteristics of septic shock? (Select all that apply.)

Altered fluid volume

Increased capillary permeability

Inhibition of inflammatory mediators

Maldistribution of circulating volume

Vasoconstriction

A, B, D

Which factor separates sepsis from septic shock?

Bands greater than 10%

Fever greater than 39.4°C (103°F)

Sepsis interventions no longer effective

WBC count greater than 12,000/mL or less than 4,000/mL

C

A client with septic shock has a high CO and tachycardia. The nurse recognizes that this combination of clinical signs suggests which type of shock?

Hyperdynamic shock

Hypodynamic shock

Mild septic shock

Severe septic shock

A

A client with a T5 spinal cord injury is in neurogenic shock. The nurse is aware that this type of shock results from which mechanism?

Unopposed parasympathetic nervous system stimulation

Loss of spinal reflex activity

Overstimulation of the sympathetic nervous system

Loss of vagal stimulation activity

A

The nurse is preparing to assess a client experiencing neurogenic shock. Which vital signs should the nurse anticipate?

BP 132/74

HR 53 bpm

RR 14/min

Temp 37.9°C (100.2°F)

B

Anaphylactic shock involves the interplay of what factors? (Select all that apply.)

Immunoglobulin IgA

Mast cells

Immunoglobulin IgE

Lymphocytes

Immunoglobulin IgM

B, C

Anaphylactic shock is associated with increased capillary permeability. Based on this particular pathophysiologic problem, which assessment should the nurse focus on immediately?

Severe diarrhea

Respiratory distress

Cardiac dysrhythmias

Urticaria and pruritus

B

In early management of pulmonary embolism, which drug is the highest priority to initiate?

Dobutamine

Morphine

Aspirin

Heparin

A

Which pathophysiologic mechanism is involved in tension pneumothorax?

Air enters the thoracic cavity but cannot escape.

Fluid accumulates in the pleural sac, compressing lung tissue.

Increased pulmonary vascular resistance exerts pressure on lung tissue.

Blood enters the thoracic cavity and compresses soft intrathoracic structures.

A

What are the major clinical manifestations of cardiac tamponade? (Select all that apply.)

Pulsus paradoxus

Decreased right atrial pressure

Decreased blood pressure

Muffled heart sounds

Severe chest pain

A, C, D

When caring for a client who has developed cardiac tamponade, the nurse can anticipate which priority emergency action?

Needle pericardiocentesis

Surgical decompression

Cardiopulmonary resuscitation

IV vasopressor therapy

A

A client is in refractory shock. What information should the nurse provide to the family?

"You should prepare yourself for your loved one's death."

"Recovery will be rapid once we complete fluid resuscitation."

"Your loved one will be hospitalized for at least a week during this recovery."

"Treatment will be prolonged and may not be successful."

Answer:

1. "You should prepare yourself for your loved one's death."

Rationale:

1. When the client is in refractory shock, cell destruction is so severe that death is inevitable.

A client who had abdominal surgery yesterday is cold, clammy, and confused. Which additional assessment findings would support concern that this client is in shock? (Select all that apply.)

Pulse rapid and weak

Arterial pH 7.49

Serum lactate level 5.8 mmol/L

Base excess 1 mmol/L

BP 88/50 mmHg

Answer:

2. Serum lactate level 5.8 mmol/L

Rationale:

2. A lactate level higher than 5 mmol/L is characteristic of lactic acidosis, which is common in the shock state.

A client having chest pain is being monitored for myocardial infarction. Which finding would the nurse evaluate as indicating the client is at risk for developing cardiogenic shock?

The client did not take aspirin prior to presenting at the emergency department.

The client has started having increased premature ventricular contractions.

The client's temperature has risen to 37.7°C (99.8°F).

The client is nauseated.

Answer:

2. The client has started having increased premature ventricular contractions.

Rationale:

2. Worsening cardiac dysrhythmia indicates a risk of cardiogenic shock. Dysrhythmia is related to irritability of the heart muscle, which can occur when ischemia is present.

A client who had a myocardial infarction yesterday was pain free until 15 minutes ago. The client now says the pain is like it was when he originally came to the emergency department. Which assessments should the nurse conduct? (Select all that apply.)

Auscultate bowel sounds.

Palpate for cardiac lifts or heaves.

Auscultate breath sounds.

Evaluate cardiac rhythm.

Review urinary output measurements.

Answer:

3. Auscultate breath sounds.

Rationale:

3. The nurse should assess respiratory sounds for crackles.

A client has hypovolemic shock as a result of massive gastrointestinal bleeding. The client is given fluids and vasopressors. Which outcome indicates to the nurse that these treatments are having the desired effect?

Base deficit is -6 mmol.

Lactate levels are decreasing from admission levels.

Urine output is normal.

Blood pressure is now 90/60 mmHg.

Answer:

2. Lactate levels are decreasing from admission levels.

Rationale:

2. Serum lactate levels can be used as an indirect measure of impaired oxygen delivery and indicate the degree of hypoperfusion. Decreasing lactate levels indicate that tissue perfusion and oxygenation are improving.

A client in septic shock has been prescribed a vasopressor medication. Which assessment finding would the nurse evaluate as indicating the need to question this order?

The client's mentation has not improved.

The client's heart rate is 50 bpm.

The client's urine output for the last hour was 10 mL.

The client's breath sounds include crackles.

Answer:

3. The client's urine output for the last hour was 10 mL.

Rationale:

3. Vasopressor medications are not effective if there is inadequate circulating blood volume. Poor urine output is one measure of insufficient fluid resuscitation.

A client in septic shock is given IV insulin therapy. The nurse would increase this infusion if which blood glucose level was measured? (Select all that apply.)

110 mg/dL

136 mg/dL

156 mg/dL

184 mg/dL

200 mg/dL

Answer:

4. 184 mg/dL

Rationale:

4. A blood glucose level of 184 mg/dL is above the recommended parameter of 180 mg/dL. The nurse should titrate the infusion upward.

A client is received in the emergency department from emergency medical services after sustaining a brain injury in a fall. She is on a spineboard and has a cervical collar in place. She is not moving her lower extremities. What would alert the nurse to the possible development of neurogenic shock?

The client reports that she feels a tingling sensation in her lower extremities.

The client's heart rate drops from 82 bpm to 68 bpm.

The client's blood glucose is 134 mg/dL.

The client's friend reports that the client was unconscious for a "few seconds" after the fall.

Answer:

2. The client's heart rate drops from 82 bpm to 68 bpm.

Rationale:

2. Bradycardia is an indicator that shock is developing. This client's heart rate is dropping, and the nurse should be aware of the potential for developing shock.

A client with a long history of chronic obstructive pulmonary disease (COPD) presents to the emergency department in respiratory distress. After assessing absence of lung sounds on the right and tracheal deviation, the nurse notifies the ED physician. What emergency intervention should the nurse anticipate?

Intubation and mechanical ventilation

Needle thoracostomy

Administration of furosemide

Pericardiocentesis

Answer:

2. Needle thoracostomy

Rationale:

2. This client shows signs of tension pneumothorax. If this proves to be the case, needle thoracostomy or chest tube placement is indicated.

A client is receiving intravenous dobutamine, which the nurse is titrating to effect. Which assessment findings would indicate the need to reduce the rate of infusion? (Select all that apply.)

The client complains of chest pain.

The client's heart rate is 110 bpm.

The client begins having ventricular dysrhythmias.

The client's blood pressure is 160/110 mmHg.

The client complains of headache.

Answer:

2. The client begins having ventricular dysrhythmias.

Rationale:

2. One of the dose-related effects of dobutamine is dysrhythmia.

Mediators that stimulate the local inflammatory response are released from which type of activated cell?

Platelets

Endothelial cells

Leukocytes

Bacteria

B

How does the endothelium orchestrate the local inflammatory response? (Select all that apply.)

By decreasing capillary permeability

By promoting adhesion of white blood cells

By altering local vasomotor tone

By inducing thrombin generation

By blocking apoptosis

B, C, D

What is the primary benefit of the redness, heat, and swelling associated with local inflammation?

It encourages the host to protect the injury site.

It destroys infective organisms.

It alters the pH of the injury area.

It facilitates entry of immune cells into the area of injury.

D

If the host inflammatory response becomes generalized, what is the result?

A reduction in secretion of mediators

Increased pain at the site of injury

Widespread involvement of endothelial cells

Localized vasoconstriction and coagulation

C

MODS is characterized by the dysfunction of how many organ systems?

One

Two or more

Three or more

Four or more

B

Primary MODS can develop in response to which factor?

The insult itself

Secondary complications

An exaggerated SIRS

Septic shock

A

Why is advancing age a risk factor for developing MODS?

Older adults do not have the money to pay for services.

Older adults do not take antibiotics as prescribed.

Older adults have decreased functional reserve.

Older adults have enhanced stress response.

C

Which pathophysiologic condition occurs as a result of anaerobic metabolism?

Metabolic shutdown

Apoptosis

Uncontrolled systemic inflammation

Microvascular coagulopathy

A

What are the results of the respiratory dysfunction associated with MODS?

A high PACO2 with a high PAO2

Increased diffusion across the alveolar membrane

Refractory hypoxia

Profound hemoptysis

C

Which finding reflects worsening cardiovascular function?

High cardiac output

Increasing PAR values

Increasing PAO2/FiO2

Tachycardia

B

Mortality in MODS-related AKI is lower in which case?

Urine output is greater than 400 mL/day.

Serum creatinine is greater than 4.0 mg/dL.

Neurologic function is maintained.

Hemodialysis is delayed until absolutely necessary.

A

What is the most severe manifestation of hematologic dysfunction?

Anemia

Thrombocytopenia

DIC

Jaundice

C

Which strategy is essential to reducing the mortality associated with MODS?

Early recognition and management of MODS

Administration of acetaminophen for febrile episodes

Prompt administration of aminoglycosides as ordered

Knowing how to operate a dialysis machine

A

What is the best way to prevent MODS?

Place the client on mechanical ventilation.

Initiate antibiotics with the onset of fever.

Ensure optimal oxygenation.

Prevent SIRS and sepsis.

D

Which nursing interventions decrease the incidence of infection? (Select all that apply.)

Monitoring vital signs every 2 hours

Strict adherence to hand hygiene

Use of a ventilator bundle

Meticulous catheter care

Maintenance of client skin integrity

B, C, D, E

The nurse has orders to obtain blood cultures and begin IV antibiotic therapy. Which statement is correct regarding these orders?

IV antibiotic should be started before obtaining blood cultures.

Blood cultures should be obtained before starting antibiotics.

The sequence in which the orders are carried out does not matter.

The prescribing provider should be consulted to clarify the orders.

B