Shock and Multiple Organ Dysfunction Syndrome

Low

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following?

Maintain activity restriction to bedrest.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Use an intravenous controller or pump.

Verify dosage and pump settings with another RN.

Measure urine output every hour.

A client is unstable and receiving dopamine to increase blood pressure. Which of the following are interventions that the nurse administering dopamine would employ? Select all that apply.

Septic

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?

Modified Trendelenburg

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

Tachycardia

When a client is in the compensatory stage of shock, which symptom occurs?

60 mm Hg

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion.

Neurogenic

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?

A rapid, bounding pulse

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

Distributive

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?

Use strict hand hygiene techniques.

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk?

Urinary output

Mental status

Vital signs

When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently? (Select all that apply.)

Oxygen at 2 L/min by nasal cannula

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Bradycardia

Which of the following is a clinical characteristic of neurogenic shock?

neurogenic shock

A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock?

Disseminated intravascular coagulation (DIC)

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient?

A myocardial infarction.

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is:

An older adult man with end-stage renal disease and an infected dialysis access site

A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is

Aortic insufficiency

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

Adrenergic drugs

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?

Head injury

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?

Distributive

The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?

Modified Trendelenburg

A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position?

Narrowed pulse pressure

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

70%

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

Nitroprusside

In the treatment of shock, which vasoactive drug results in reduced preload and afterload, reducing the oxygen demand of the heart?

Shallow, rapid respirations

The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock?

5% albumin

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer?

In the compensation stage, catecholamines are released.

You are holding a class on shock for the staff nurses at your institution. What would you tell them about the stages of shock?

Organ damage

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?

3:1

The nurse is caring for a client admitted to the emergency department with hypovolemic shock. What most appropriate ratio of IV replacement fluids does the nurse anticipate?

Mean arterial pressure of 70 mm Hg

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation?

Adventitious breath sounds

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits

Compensatory stage

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?

Fluid circulating in the blood vessels decreases.

The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when:

Progressive

The nurse assesses a BP reading of 80/50 mm Hg from a patient in shock. What stage of shock does the nurse recognize the patient is in?

Circulatory (distributive)

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?

Albumin

Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage?

Place the client in the modified Trendelenburg position.

Initiate an intravenous (IV) site and prescribed IV fluids.

Assess the capillary blood glucose level.

Collect a stool specimen for culture.

A client with diabetes is in the emergency department because of vomiting, diarrhea, and weight loss of 8 pounds over 2 days. Vital signs taken by the triage nurse indicate the client is in hypovolemic shock. Place the nurse's steps in the correct order.