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NURS 406 test 1 Questions and Answers
cardiac - ANS-✅... neuro - ANS-✅..... behavioral health - ANS-✅ Patient is receiving an IV infusion of heparin and was started on warfarin therapy the night before. which statement is most correct? A. the patient is receiving a double dose of anticoagulants B. the heparin therapy was ineffective, so the warfarin was started. C. the heparin provides anticoagulation until therapeutic levels of warfarin are reached. D. the heparin and warfarin work together synergistically to provide anticoagulation - ANS-✅C. the heparin provides anticoagulation until therapeutic levels of warfarin are reached. coumadin (warfarin) takes a few days for therapeutic levels to be reached. we may end up putting a pt on both of these initially to get the anticoagulation under control, and then once the coumadin levels are okay, the pt will come off of heparin MASLOWS hierarchy of needs - ANS-✅5 levels 1 is ultimate priority 1 - physiological: oxygen, fluids, nutrition, body temperature, elimination, shelter, sex 2 - safety and security: physical and psychological safety 3 - love and belonging needs 4 - self esteem 5 - self actualization (dreams, hopes, goals) double bind messages - ANS-✅Bateson and colleagues (1956) coined the term double-bind messages. They are characterized by two or more mutually contradictory messages given by a person in power or someone attempting to gain or maintain power. Opting for either choice will result in displeasure of the person in power. Example: Dr. Shepard asks Dr. Onori to teach one of the topics in nursing research because she knows Dr. Onori teaches that topic very well. On the day of the lecture, Dr. Onori just informs Dr. Shepard that he is going to the beach with his family and thus can't teach the topic. Dr. Shepard looks into the eyes of Dr. Onori and says, okay, that's fine, enjoy your vacation knowing very well that she has not prepared to teach the research topic for that day. The content from Dr. Shepard becomes contradictory to Dr. Onori. the "miracle" question - ANS-✅a clarifying technique (along with paraphrasing, restating, reflecting, exploring, and projective questions) The miracle question is a goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish. The question should be asked deliberately and dramatically Example: "Now, I want to ask you a strange question. Suppose that while you are sleeping tonight...a miracle happens. The miracle is that the problem that brought you here is solved... When you wake up tomorrow morning, what will be different that will tell you that a miracle has happened?" the backbone of a nurse-client relationship is - ANS-✅patient centered care (gold standard)
-dignity and respect -information sharing -pt and family participation -collaboration in policy and program development social relationship - ANS-✅primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task •Participants share ideas, feelings, and experiences during SRs to facilitate meeting of mutual needs •There is little emphasis on the evaluation of the interaction during SRs •SRs do not benefit patients because the nurse unconsciously ignores the concerns of patients therapeutic relationship - ANS-✅In a TR, the nurse maximizes communication skills, understanding of human behaviors, and personal strengths to enhance the client's growth •Clients are more likely to engage in a relationship when the clinician's interactions address their concerns, respect clients as partners in decision making, and use easy-to-understand language •In a TR, the focus should be on the client's ideas, needs, problems, experiences, and feelings. It's all about the welfare of the client Morally, legally, and ethically trained nurses and nursing students do not have ______________ relationships with patients - ANS-✅intimate these are forbidden among nurses/students with patients/clients You are about to initiate your first contact with Becky. Which is the most suitable goal in establishing the therapeutic relationship? •Establish friendship and a sense of fun •Ensure that mutual needs will be met •Establish clear boundaries while identifying patient needs •Ensure two-way communication to give or ask for help - ANS-✅•Establish clear boundaries while identifying patient needs A therapeutic relationship demonstrates the following qualities: Needs of patient identified and explored Clear boundaries established Problem-solving approaches taken New coping skills developed Behavioral change encouraged The other choices listed here are more appropriate to a social relationship. Peplau's model of nurse patient relationship - ANS-✅POWT Phases: Preorientation orientation working termination
A.Stop questioning so much and just give him some good advice so he'll trust you. B.Express honest disapproval of his resistance to help. C.Ask him pointblank why he is evading you. D. Ask a miracle question - ANS-✅ANS: D ask a miracle question The miracle question is a goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish. While Noah is anxious about saying anything specific about what is troubling him, he may be able to talk about what he might wish for. This very basic question often gets to the source of the most important issues in a person's thinking and life. The other three solutions here are all excellent examples on nontherapeutic communication techniques. As a nurse assesses a new client, the nurse makes sure the door remains open. Which type of communication factor is this action? A.Environmental B.Relationship C.Personal - ANS-✅A. Environmental Environmental factors that may affect communication include physical factors (e.g., background noise, lack of privacy, uncomfortable accommodations) and societal determinants (e.g., sociopolitical, historical, and economic factors, the presence of others, expectations of others). Becky tells you, "I have something secret to tell you, but you can't tell anyone else." The nurse agrees. What is the likely consequence of the nurse's action? A.Healthy feelings of sympathy by the nurse toward the client. B.Blurred boundaries in the nurse-client relationship. C.Improved rapport between the nurse and client. D.Enhanced trust between the nurse and client - ANS-✅ANS: B Keeping secrets indicates that the nurse is overly involved and is one aspect of blurred boundaries. A client with a severe allergy has been administered a high dose of antihistamine. The nurse finds that the client is drowsy and dizzy. Which type of need would the nurse prioritize in the client according to Maslow's hierarchy of needs? Safety need Belonging need Self-esteem need Self actualization need - ANS-✅Safety need Clients suffering from the effects of a high dose of antihistamines have strong safety needs. The belonging need is fulfilled when the client is provided love and compassion. Self-esteem needs are fulfilled by providing recognition. Self-actualization needs may not be the priority of the client in the current situation. EAQs - ANS-✅practice questions
A client who has sustained an accident says, "I have a dream of conquering the world's highest mountain range." To which level of need does the given scenario refer to, according to Maslow's hierarchy of needs? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the fourth level that includes self-esteem needs. The given scenario relates to the final level that includes self-actualization needs. The given scenario relates to the second level that includes safety and security needs. - ANS-✅The given scenario relates to the final level of Maslow's hierarchy of needs: the self-actualization needs. The self-actualization need refers to self-fulfillment. Physiological needs refer to the need for clean air, water, and food. Self-esteem needs refer to self-confidence, usefulness, achievement, and self-worth. Safety and security needs refer to physical and psychological security. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. A client says "I feel frustrated because I do not spend enough time with my partner because of my job." According to Maslow's hierarchy of needs, which level of need does the given scenario refer? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the second level that includes safety and security needs. The given scenario relates to the third level that includes love and belonging needs. The given scenario relates to the final level that includes self-actualization needs. - ANS-✅The given scenario relates to the third level that includes love and belonging needs. The love and belonging need is the third level of need in the Maslow's hierarchy of needs. This includes maintaining friendships, social relationships, and intimate relationships. In the given scenario, the client demonstrates that he or she wants to spend more time with his or her partner. Thus, this is an example of the third level of needs. A client says, "I do not want to go back to school because I fear that everyone will laugh at me." Which level of need does the given scenario refer to according to Maslow's hierarchy of needs? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the second level that includes safety and security needs. The given scenario relates to the fourth level that includes self-esteem needs.
"A client tells the nurse that he or she wishes to become a successful engineer despite having dyslexia." "A client who is bedridden requests a physical therapist consultation in order to achieve maximum mobility." - ANS-✅"A client wishes to become the best swimmer in the whole world." "A client tells the nurse that he or she wishes to become a successful engineer despite having dyslexia." "A client who is bedridden requests a physical therapist consultation in order to achieve maximum mobility." According to Maslow's hierarchy of needs, the fifth level of needs include self-actualization needs. At this level, the individual wishes to reach his or her maximum potential while coping realistically with the situations of life. A client who wants to become the best swimmer in the world, become a successful engineer, or achieve maximum mobility after being bedridden is displaying self-actualization needs. Feeling the urge to urinate every 10 minutes is a physiological health problem that belongs to the first level of needs. A client who feels like a failure for not being able to complete college education may have a lack of self-worth and achievement. This situation belongs to the fourth level of needs.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation. A nursing student is citing examples of situations based on Maslow's hierarchy of needs. Which situations belong to the first level of needs? Select all that apply. "A client informs the nurse that he or she is a homeless person." "A client tells the nurse that he or she has been feeling dizzy for two days." "A client tells the nurse that he or she is beaten up repeatedly by a neighbor." "A client tells the nurse that he or she is unable to consume food because of throat pain." "A client informs the nurse that he or she is going to walk one day even after undergoing leg amputation." - ANS-✅"A client informs the nurse that he or she is a homeless person." "A client tells the nurse that he or she has been feeling dizzy for two days." "A client tells the nurse that he or she is unable to consume food because of throat pain." According to Maslow's hierarchy of human needs, the first level constitutes physiological needs such as air, water, food, and body temperature. A homeless client who lacks shelter probably does not receive enough food to eat. This indicates a physiological need. A client who has been feeling dizzy for two days might have some serious underlying health issue. This is an example of a first level need. A client who is unable to eat food because his or her throat hurts may need pain medication, which is a first level need. A client who may be harmed physically by a neighbor may need security. This is an example of a second level need. Fifth level needs are self-actualization needs. A client who has undergone leg amputation and wishes to be able to walk again is an example of a client with a fifth level need. A registered nurse is teaching a nursing student about Maslow's hierarchy of needs. Which statement made by the nursing student needs correction? "The hierarchy of basic human needs includes five levels of priority."
"The second level includes safety and security needs, which involve physical and psychological security." "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life." - ANS-✅"The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization. Which level of Maslow's hierarchy of needs is fulfilled by the nurse fitting a client who nearly died of asphyxiation with an oxygen mask? First level Second level Third level Fourth level - ANS-✅First level. The first level of Maslow's hierarchy of needs includes the most basic and physiologic needs like air, water, and food. Therefore fitting a client with an oxygen mask meets the basic physiological needs. The second level includes safety and security needs, which involve physical and psychological security. The third level includes love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses self-esteem needs, which involve self- confidence, usefulness, achievement, and self-worth. Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply. Self worth Achievement Security needs Belonging needs Self actualization - ANS-✅self worth achievement Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self- confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self- actualization is the basic human need, which belongs to the final level. A client with severe breathing problems is brought to the emergency ward. Which level of Maslow's hierarchy of needs does the nurse need to follow? First level
if he or she does something good, this statement is an example of self-esteem needs.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client would meet the self-esteem need? "I fear that my partner will leave me because of my illness." "I want to stay fit because my aim is to be a successful entrepreneur." "I do not have anyone in my life, as my family has disowned me." "I tend to get worried about every little thing because I cannot do anything successfully." - ANS-✅"I tend to get worried about every little thing because I cannot do anything successfully." According to the Maslow's hierarchy of needs model, certain human needs are more basic than others. When a client says that he or she tends to worry about every little thing because he or she cannot do anything successfully, this is an example of self-esteem needs. When a client says that he or she fears that his or her partner will leave him or her because of his or her illness, this statement is an example of safety and security needs. When a client says that he or she wants to stay fit to become a successful entrepreneur, this statement is an example of self-actualization needs. When a client says that he or she does not have anyone in his or her life because of being disowned by his or her family, this statement is an example of love and belonging needs. A nurse caring for a client prioritizes nursing actions based on Maslow's hierarchy of needs. Which statement made by the client meets the love and belonging need? "I do not like the way I look, speak, or act." "I dream of becoming the richest person in the world." "I hardly speak to my children because they live in different countries." "I want to go back home because I am afraid of the tests you are performing." - ANS-✅"I hardly speak to my children because they live in different countries." If a client says that he or she hardly speaks to his or her children because they live in different countries, this statement is an example of the love and belonging need according to Maslow's hierarchy of needs. If a client says that he or she does not like the way he or she looks, speaks, or acts, this statement is an example of low self-esteem. Here, the nurse needs to address the client's self-esteem needs. If a client says that he or she dreams of becoming the richest person in the world, this statement is an example of self-actualization needs. If a client says that he or she wants to go back home because he or she is afraid of the tests being performed, this statement is an example of safety and security needs. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which activities should the nurse perform to meet the client's safety and security needs? Select all that apply.
Providing a cold bath to reduce the client's body temperature Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents Collaborating with family members to provide emotional support for the client post-surg - ANS- ✅Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents As per Maslow's hierarchy of needs, to meet the safety and security needs of the client, the nurse should position the bed in a low position and keep the side rails up to provide physical safety for the client. Monitoring vital signs, including blood pressure to prevent risk for falls is an example of a nursing activity that meets the client's safety and security needs. Observing a client who has suicidal tendencies to prevent adverse incidents is an example of a nursing activity that meets the client's safety and security needs. Providing a cold bath to the client to reduce body temperature is an example of a nursing activity that meets the client's physiological needs. Collaborating with family members to provide emotional support to the client post-surgery is an example of a nursing activity that meets the client's love and belonging needs. A nurse is assessing a client by using Maslow's hierarchy of needs. In which order should the nurse prioritize care? - ANS-✅1.Physiological 2.Safety and security 3.Love and belonging 4.Self-esteem 5.Self-actualization According to Maslow's hierarchy of needs, the nurse should prioritize physiological needs because these are basic human needs. The nurse should then address safety and security, which includes physical and psychological safety. Next, the nurse should address love and belonging needs. After this, the nurse should attend to the client's self-esteem needs. Finally, the nurse should address self-actualization needs. A nursing student is reviewing different statements as they fulfill Maslow's hierarchy of needs, from the highest level of needs to the lowest level of needs. In which order should the nursing student arrange the scenarios, from the highest the lowest level of needs? Correct1.A client says to the nurse, "I want to maintain good health as I intend to be the best soccer player on my team." Correct2.A client says to the nurse, "I do not have any skills that will help me be an achiever in life." Correct3.A client says to the nurse, "I have been feeling depressed ever since my sibling stopped speaking to me." Correct4.A client says to the nurse, "My father threatens to commit me to an asylum if I dare disobey him." - ANS-✅Correct1.A client says to the nurse, "I want to maintain good health as I intend to be the best soccer player on my team." Correct2.A client says to the nurse, "I do not have any skills that will help me be an achiever in life." Correct3.A client says to the nurse, "I have been feeling depressed ever since my sibling stopped speaking to me."
"Ever since my family members came to know about my problem they are trying to avoid me." - ANS-✅"I do not want to talk to any stranger as I fear that they might take away my things." The nurse should attend to the safety and security needs of the client by addressing the client's fear of strangers. When the client says that he/she is on liquid diet, the nurse should consider this as a possible lack of nutrition. This is a physiological need. When the client says that his/her blood pressure level fluctuates, the nurse should consider this as an example of physiological needs. When the client says that his/her family members avoid him/her as he/she has dementia, the nurse should understand this to be a love and belonging need. A nurse is prioritizing client-care by using Maslow's hierarchy of needs. Which situation should the nurse address to meet the self-actualization needs of the client? A client says, "I want to be a world class athlete." A client says, "I do not want to go home because no one there cares." A client says, "I am not feeling good. Can you please check if I have fever?" A client says, "Whatever I do for my family or for my loved ones does not actually help them." - ANS-✅A client says, "I want to be a world class athlete." According to Maslow's hierarchy of needs, self-actualization is the desire to reach one's full potential. In the given scenario, the nurse should address the client who wants to be a world class athlete to address self-actualization needs. When a client says that he/she does not want to go back home as there is no one there that cares, this comes under love and belonging needs. When a client says that he/she is feeling feverish, this comes under physiological needs, which address the basic requirements of an individual. When a client says that whatever he/she does for his/her family and loved ones do not actually help them, it is an example of low self-esteem. Here, the nurse should address the self-esteem needs of the client. A nurse is evaluating examples of situations pertaining to the basic needs of human beings according to Maslow's hierarchy of needs. Which situations qualify under the fourth level of needs? Select all that apply. A client laments that he or she is the ugliest person in the whole world. A client informs the nurse that he or she has been living alone for the past decade. A client tells the nurse that he or she feels out of breath even when walking slowly. A client tells the nurse that he or she is the only member in the family who does not work. A client feels that he or she has not been able to live up to his or her partner's expectations. - ANS-✅A client laments that he or she is the ugliest person in the whole world. A client feels that he or she has not been able to live up to his or her partner's expectations.
According to Maslow's hierarchy of needs, the fourth level needs constitute the esteem and self-esteem needs. This includes self-confidence, usefulness, achievement, and self-worth. The client who believes that he or she is the ugliest person in the whole world displays a lack of self-worth. This is an example of a fourth level need. A client who informs the nurse that he or she is the only family member who does not work displays a lack of achievement and usefulness. This is another example of the fourth level needs. A client who tells the nurse that he or she has not been able to live up to his or her partner's expectations indicates a lack of achievement and self-worth. This is also an example of esteem and self- esteem needs. A client who has been living alone for a decade indicates a lack of social interactions and social relationships. This is an example of third level needs (love and belonging). Physiological needs such as difficulty breathing is a first level need. A nurse is evaluating different situations related to addressing different levels of client needs. According to Maslow's hierarchy of needs, in which order should the nurse prioritize his or her actions? 1.Encouraging the client to talk about his or her fears and feelings 2.Providing a warm bath to the client to promote a good night's sleep 3.Praising the client for administering insulin accurately 4.Assisting the client in getting out of bed to join family members for meals - ANS-✅1.Providing a warm bath to the client to promote a good night's sleep 2.Encouraging the client to talk about his or her fears and feelings 3.Assisting the client in getting out of bed to join family members for meals
- Praising the client for administering insulin accurately According to Maslow's hierarchy of needs, the basic needs of the client should be addressed first before moving toward the highest level of need. Thus, providing a warm bath to promote a good night's sleep addresses the physiological (basic) need of the client. The next level of need is the safety and security need. The nurse encourages the client to talk about his or her fears and feelings to meet this need. The next level is the love and belonging need. The nurse assists the client in getting out of bed and joining family members for meals meets this need. Finally the nurse addresses the self-esteem need by praising him or her for administering insulin accurately. Which action is the least likely to prevent sleep disturbances? Avoiding reading, writing, and eating in bed Getting out of bed if unable to fall sleep after 20 minutes Performing strenuous exercise within an hour before going to bed Lowering the temperature of the bedroom and keeping it dark and quiet - ANS-✅Performing strenuous exercise within an hour before going to bed To prevent sleep disturbances, a client should not perform strenuous exercise within six hours before bedtime. A client should avoid reading, writing, and eating in bed. To prevent sleep disturbances, a client should get out of bed if he or she is not able to fall sleep after 20 minutes. The client should also lower the temperature of the bedroom and keep it dark and quiet. A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe?
Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level - ANS-✅metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock. A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? Diuresis, irritability, and fever Lethargy, cold skin, and hypertension Thirst, cool skin, and orthostatic hypotension Bounding pulse, restlessness, and slurred speech - ANS-✅Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech. The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Rapid pulse Deep respirations Warm, flushed skin Increased blood pressure Decreased urinary output - ANS-✅Rapid pulse Decreased urinary output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure. During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?
Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis - ANS-✅metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock. The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply. Polyuria Dyspnea Diaphoresis Tachycardia Hypertension - ANS-✅Dyspnea Diaphoresis Tachycardia Shortness of breath and an increase in the respiratory rate occur with cardiogenic shock. Cold, clammy (diaphoresis) skin occurs because of vasoconstriction associated with stimulation of the sympathetic nervous system. The heart rate increases (tachycardia) as the heart attempts to maintain cardiac output and circulating blood volume. A decrease in circulation of blood to the kidneys results in oliguria, not polyuria. Hypotension, not hypertension, is a sign of cardiogenic shock; the systolic reading is often below 90 mm Hg. What is the term for shock associated with a ruptured abdominal aneurysm? Vasogenic shock Neurogenic shock Cardiogenic shock Hypovolemic shock - ANS-✅Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output. A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? Cold, clammy skin Slow, bounding pulse Increased blood pressure Hyperactive bowel sounds - ANS-✅Cold clammy skin The action of the sympathetic nervous system causes vasoconstriction, and as cellular and peripheral hypoperfusion progresses, the skin becomes cold, clammy, cyanotic, or mottled. The heart rate increases
caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord. The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? Oliguria Crackles Dyspnea Bounding Pulse - ANS-✅Oliguria Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, as well as with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia. A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. Oliguria Bradypnea Diaphoresis Tachycardia Hypertension - ANS-✅Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output. Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume. During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis - ANS-✅Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid associated with the progressive stage of shock. Respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis occurs as a result of hyperventilation during early shock. A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? The body initially attempts to compensate by releasing more red blood cells.
The body initially attempts to compensate by maintaining peripheral vasoconstriction. The body initially attempts to compensate by decreasing mineralocorticoid production. The body initially attempts to compensate by producing less antidiuretic hormone (ADH). - ANS-✅The body initially attempts to compensate by maintaining peripheral vasoconstriction. With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure. The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the client is stabilized, what intervention should the nurse do next? Monitor the peripheral pulses. Check the level of consciousness. Take a blood sample for laboratory tests. Control the bleeding with a pressure dressing. - ANS-✅Take a blood sample for laboratory tests. The primary nursing intervention that should be followed in the client's condition with gastrointestinal bleeding is collection of a blood sample for laboratory diagnosis. Peripheral pulses are monitored in an ongoing manner. Level of consciousness may not be required to be monitored based on the client's condition. Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and wounds. To prevent septic shock in the hospitalized client, what should the nurse do? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands. - ANS-✅Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock. A client with severe breathing problems is brought to the emergency ward. Which level of Maslow's hierarchy of needs does the nurse need to follow? First level Second level Third level Fourth level - ANS-✅first level The first level of Maslow's hierarchy of needs includes physiological needs like air, water, and food. Since the client has difficulty breathing, sufficient air should be provided as the first step of nursing
