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NU371: SHOCK AND MULTIPLE ORGAN DYSFUNCTION
SYNDROME: TEST QUESTIONS WITH COMPLETE
SOLUTIONS
- You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? a) Obstructive b) Hypovolemic c) Carcinogenic d) Circulatory (distributive) -- Correct Answer ✔✔ d) Circulatory (distributive) Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
- 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. a) 60 mm Hg b) 70 mm Hg c) 80 mm Hg d) 90 mm Hg -- Correct Answer ✔✔ a) 60 mm Hg Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.
- During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? a) Liver b) Kidneys c) Lungs d) Brain -- Correct Answer ✔✔ d) Brain The body displays a "fight-or-flight" response, with the release of catecholamines. Blood will be shunted to the brain, heart, and lungs to ensure adequate blood supply. The organ that will always be protected over the others is the brain.
- A client is exhibiting a systolic blood pressure of 72, a pulse rate of 168 beats per minute, and rapid, shallow respirations. The client's skin is mottled. The nurse assesses this shock as a) Hypovolemic b) Progressive c) Neurogenic d) Compensatory -- Correct Answer ✔✔ b) Progressive The vital signs and skin condition are those of a client in the progressive stage of shock. Data are insufficient to support shock as either hypovolemic or neurogenic in origin.
- 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? a) Initial stage b) Compensatory stage c) Progressive stage d) Irreversible stage -- Correct Answer ✔✔ b) Compensatory stage In the compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. In all other stages of shock, hypotension is present as compensatory mechanisms no longer suffice to maintain normal blood pressure.
Compensatory mechanisms include the release of catecholamines, activation of the renin-angiotensin-aldosterone system, production of antidiuretic and corticosteroid hormones are all mechanisms activated in the compensation stage of shock. Shock does not begin in the decompensation stage.
- 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? a) Central venous pressure of 6 mm Hg b) Mean arterial pressure of 70 mm Hg c) Urine output of 0.2 mL/kg/hr d) ScvO2 of 60% -- Correct Answer ✔✔ b) Mean arterial pressure of 70 mm Hg The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.
- Which of the following is a clinical characteristic of neurogenic shock? a) Bradycardia b) Tachycardia c) Cool skin d) Moist skin -- Correct Answer ✔✔ a) Bradycardia The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.
- 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? a) Unstable angina pectoris b) Aortic insufficiency c) Hypertension
d) Diabetes mellitus -- Correct Answer ✔✔ b) Aortic insufficiency A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.
- The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. a) Vomiting b) Burns c) Diarrhea d) Dehydration e) Trauma -- Correct Answer ✔✔ b) Burns d) Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.
- Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Famotidine (Pepcid) b) Nizatidine c) Lansoprazole d) Desmopressin e) Furosemide -- Correct Answer ✔✔ a) Famotidine (Pepcid) b) Nizatidine c) Lansoprazole Antacids, H2 blockers (Pepcid, Axid), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or
output. Epinephrine (Adrenaline) improves contractility, increases stroke volume, and increases cardiac output. Methoxamine (Vasoxyl) increases blood pressure by vasoconstriction.
- Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Head injury b) Myocardial infarction c) Diabetes d) Multiple sclerosis -- Correct Answer ✔✔ a) Head injury An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.
- 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? a) liver dysfunction b) organ damage c) weight loss d) unsteady gait -- Correct Answer ✔✔ b) organ damage When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.
- A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first? a) Obtain the name and information of the allergic substance. b) Administer an epinephrine injection as ordered by the health care provider. c) Obtain a health history.
d) call 911 -- Correct Answer ✔✔ b) Administer an epinephrine injection as ordered by the health care provider. The key words in the question are "increasing symptoms." The first action of the nurse is to administer an epinephrine injection to abort the rapidly increasing symptoms. Next, the nurse will call 911.
- A nurse is caring for a client in the compensatory stage of shock. What clinical finding would the client exhibit? a) PaCO2 <32 mm Hg b) compensatory respiratory alkalosis c) heart rate >20 bpm d) metabolic acidosis -- Correct Answer ✔✔ b) compensatory respiratory alkalosis In the compensatory stage of shock, a client will have a compensatory respiratory alkalosis with the rise of the respiratory rate, causing removal of CO2 and a rise the blood pH. The Pa CO2 would be increased in compensatory stage of shock. The client's heart rate would be tachycardic in the compensatory stage of shock. Metabolic acidosis is part of the late stages of shock, as anaerobic metabolism results in the accumulation of toxic end products, especially lactic acid.
- A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing? a) Anaphylactic shock b) Neurogenic shock c) Septic shock d) Hypovolemic shock -- Correct Answer ✔✔ b) Neurogenic shock Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Septic shock is caused by
- A client is scheduled for computed tomography (CT) scanning of the abdomen and reports an allergy to iodine. The best action of the nurse is to a) Ask the client "How does your allergy manifest itself?" b) Notify the radiologist of the allergy to iodine. c) Inform the ordering physician that the CT scan cannot be performed. d) Send the client for the CT scan, noting the allergy to iodine on the front of the chart. -- Correct Answer ✔✔ a) Ask the client "How does your allergy manifest itself?" The nurse must assess the client for reactions to contrast agents. This would include the type of reaction. The nurse then communicates this information to the staff involved in the care of the client.
- 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 a) A young female adolescent who developed shock from tampon use during menses b) An older adult man with end-stage renal disease and an infected dialysis access site c) An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic infection d) A middle-aged woman with metastatic breast cancer and a BMI of 26 -- Correct Answer ✔✔ b) An older adult man with end-stage renal disease and an infected dialysis access site MODS may develop when a client experiences septic shock. Those at increased risk for MODS are older clients, clients who are malnourished, and clients with coexisting disease.
- 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? a) Septic b) Anaphylactic c) Neurogenic
d) Cardiogenic -- Correct Answer ✔✔ a) Septic In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.
- The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? a) A rapid, bounding pulse b) A slow but steady pulse c) A weak and thready pulse d) A slow and imperceptible pulse -- Correct Answer ✔✔ a) A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.
- The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? a) Low b) High c) Normal d) Unable to measure -- Correct Answer ✔✔ a) Low The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.
- A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy: a) The balloon deflates prior to systole.
- Shock occurs when tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function. When caring for patients who may develop indicators of shock, the nurse is aware that the most important measurement of shock is: a) Blood pressure. b) Breath sounds c) Renal output d) Heart rate -- Correct Answer ✔✔ a) Blood pressure. By the time the blood pressure drops, damage has already been occurring at the cellular and tissue levels. Therefore, the patient at risk for shock must be monitored closely before the blood pressure drops.
- 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? a) hypervolemic b) distributive c) restrictive d) cardiotonic -- Correct Answer ✔✔ b) distributive The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. This makes options A, C, and D incorrect.
- The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? a) Administer recombinant human activated protein C (rhAPC) as prescribed. b) Begin a continuous IV infusion of insulin per protocol. c) Initiate enteral feedings as prescribed. d) Administer norepinephrine as prescribed. -- Correct Answer ✔✔ d) Administer norepinephrine as prescribed. Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the
initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.
- A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a) Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family. -- Correct Answer ✔✔ a) Encourage the family to touch and talk to the client. The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.
- 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? a) Elevated systolic blood pressure b) Elevated mean arterial pressure c) Shallow, rapid respirations d) Bradycardia -- Correct Answer ✔✔ c) Shallow, rapid respirations A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock; mean arterial pressure is less than 65 mm Hg. Bradycardia occurs in neurogenic shock, but other states of shock are normally accompanied by tachycardia.
b) disseminated intravascular coagulation c) acute respiratory distress syndrome d) hypoglycemia e) GERD -- Correct Answer ✔✔ a) kidney failure b) disseminated intravascular coagulation c) acute respiratory distress syndrome When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.
- A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? a) Epinephrine b) Benadryl c) Proventil d) Prednisone -- Correct Answer ✔✔ a) Epinephrine Epinephrine is given for its vasoconstrictive actions, as well as for its rapid effect of reducing bronchospasm. Benadryl and Proventil (nebulized) are given to reverse the effects of histamine. Prednisone is given to reduce inflammation, if necessary.
- 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? a) Modified Trendelenburg b) Trendelenburg c) Semi-Fowler's d) Supine -- Correct Answer ✔✔ a) Modified Trendelenburg The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for
hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.
- 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? a) Initial b) Compensatory c) Progressive d) Irreversible -- Correct Answer ✔✔ c) Progressive In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.
- The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? a) Decreased white blood cell count b) Increase in arterial oxygenation c) Decreased depressive symptoms d) Regulation of sodium and potassium -- Correct Answer ✔✔ b) Increase in arterial oxygenation Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
