A nurse in the ICU is planning the care of a client who is being treated for shock. What statement best describes the pathophysiology of this client's health problem?
Blood is shunted from vital organs to peripheral areas of the body.
Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?
Fluid volume circulating in the blood vessels decreases.
There is an uncontrolled increase in cardiac output.
Blood pressure regulation becomes irregular.
The client experiences tachycardia and a bounding pulse.
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
Increased urine output
Decreased heart rate
Hyperactive bowel sounds
Cool, clammy skin
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer?
Lactated Ringer
Albumin
Dextran
3% NaCl
A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse's care planning during the administration of a vasoactive drug?
The drug should be discontinued immediately after blood pressure increases.
The drug dose should be tapered down once vital signs improve.
The client should have arterial blood gases drawn every 10 minutes during treatment.
The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.
A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client’s blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing?
Anaphylactic shock
Neurogenic shock
Septic shock
Hypovolemic shock
The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs?
The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate
The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
The release of catecholamines that creates an increase in metabolic rate and caloric requirements
The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea
The nurse is transferring a client who is in the progressive stage of shock into the intensive care unit from the medical unit. Nursing management of the client should focus on which intervention?
Reviewing the cause of shock and prioritizing the client's psychosocial needs
Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
Giving the prescribed treatment, but shifting focus to providing family time as the client is unlikely to survive
Promoting the client's coping skills in an effort to better deal with the physiologic changes accompanying shock
When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal?
Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping.
Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature.
Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention?
Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good
Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months
Promoting communication with the client and family along with addressing end-of-life issues
Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock?
Increased hunger
Decreased thirst
Decreased urinary output
Increased capillary perfusion
The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock?
Elevated systolic blood pressure
Elevated mean arterial pressure (MAP)
Shallow, rapid respirations
Bradycardia
The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor?
Hypothermia
Coffee ground emesis
Pain
The nurse is caring for a client in intensive care unit whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize?
Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug titration
Reviewing medications, performing a focused cardiovascular assessment, and providing client education
Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema
Routine monitoring of vital signs, monitoring the peripheral intravenous site, and providing early discharge instructions
The nurse in intensive care unit is admitting a 57-year-old client with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to which preliminary conclusion?
The client is in the compensatory stage of shock.
The client is in the progressive stage of shock.
The client will stabilize and be released by tomorrow.
The client is in the irreversible stage of shock.
The nurse in a rural nursing facility will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after giving birth at home. Which principle should guide the nurse's administration of intravenous fluid?
5% albumin is preferred because it is inexpensive and is always readily available.
Dextran should be given because it increases intravascular volume and counteracts coagulopathy.
Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency.
Lactated Ringer solution is ideal because it increases volume, buffers acidosis, and is the best choice for clients with liver failure.
The nurse in the intensive care unit is caring for a 47-year-old, obese client who is in shock following a motor vehicle accident. What would be the main challenge in meeting this client's elevated energy requirements during prolonged rehabilitation?
Loss of adipose tissue
Loss of skeletal muscle
Inability to convert adipose tissue to energy
Inability to maintain normal body mass
The nurse in the emergency department is caring for a client recently admitted with a likely myocardial infarction (MI). The nurse understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. The nurse knows the client is at an increased risk for MI due to which factor?
Arrhythmias
Elevated B-natriuretic peptide (BNP)
Use of thrombolytics
Dehydration
The nurse is caring for a client admitted with cardiogenic shock. The client is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this client?
It promotes coping and slows catecholamine release.
It stimulates the client so he or she is more alert.
It decreases gastric secretions.
It dilates the blood vessels.
The nurse is providing care for a client who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What compensatory mechanism will increase the client's cardiac output during the hypovolemic state?
Third spacing of fluid
Dysrhythmias
Tachycardia
Gastric hypermotility
The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply.
Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines
Hypotension that responds to bolus fluid resuscitation
Exaggerated response to vasoactive medications
Serum lactate greater than 4 mmol/L
Mean arterial pressure (MAP) of less than 65 mm Hg
An adult client has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this client. What aspect of this care should be prioritized by the home health nurse?
Providing supervision to home health aides in providing necessary client care
Assisting the client and family to identify and mobilize community resources
Providing ongoing medical care during the family's rehabilitation phase
Reinforcing the importance of continuous assessment with the family
A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock?
Aggressive hypoglycemic control
Administration of hypertonic IV fluids
Early provision of nutritional support
Aggressive antibiotic therapy
The nurse is caring for a client in shock who is receiving enteral nutrition. What is the basis for enteral nutrition being the preferred method of meeting the body's needs?
It slows the proliferation of bacteria and viruses during shock.
It decreases the energy expended through the functioning of the GI system.
It assists in expanding the intravascular volume of the body.
It promotes GI function through direct exposure to nutrients.
The intensive care unit nurse is caring for an acutely ill client with signs of multiple organ dysfunction syndrome (MODS). The nurse knows the client is at risk for developing MODS due to all of the following EXCEPT:
Malnutrition
Advanced age
Multiple comorbidities
Progressive dyspnea
A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply.
Hypovolemia
Difficulty breathing
Cardiovascular overload
Pulmonary edema
Hypoglycemia
The intensive care unit nurse is caring for a client in distributive shock who is experiencing pooling of blood in the periphery. The nurse should assess for signs and symptoms of:
increased stroke volume.
increased cardiac output.
decreased heart rate.
decreased venous return.
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of distributive shock should the nurses identify? Select all that apply.
Anaphylactic
Hypovolemic
Cardiogenic
Septic
Neurogenic
A triage nurse in the emergency department (ED) is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while they were waiting for the child’s parent to get off work. Rapid onset of which condition would lead the nurse to suspect that the child is experiencing anaphylactic shock?
Acute hypertension
Respiratory distress
Neurologic compensation
Cardiac arrest
The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?
Hypertension
Cool, moist skin
Signs of sympathetic stimulation
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify?
Absence of infarcts or emboli
Reduced stroke volume and cardiac output
Absence of pulmonary and peripheral edema
Maintenance of adequate mean arterial pressure
The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way?
Through a central venous line
By a gravity infusion IV set
By IV push for rapid onset of action
Mixed with parenteral feedings to balance osmosis
The ICU nurse is caring for a client in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the client?
Anaphylaxis
Decreased oxygen consumption
Abdominal compartment syndrome
Decreased serum osmolality
The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?
Urinary output increases
Skin becomes warm and dry
Adventitious lung sounds occur in the upper airway
Heart and respiratory rates are elevated
An 11-year-old client has been brought to the emergency department by their parent, who reports that the client may be having a "really bad allergic reaction to peanuts" after trading lunches with a peer. The triage nurse's rapid assessment reveals the presence of respiratory and cardiac arrest. Which interventions should the nurse prioritize?
Establishing central venous access and beginning fluid resuscitation
Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
Establishing peripheral intravenous (IV) access and administering IV epinephrine
Performing a comprehensive assessment and initiating rapid fluid replacement
A client is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the client's care?
Communicate clearly and frequently with the client's family.
Taper down interventions slowly when the prognosis worsens.
Transfer the client to a subacute unit when recovery appears unlikely.
Ask the client's family how they would prefer treatment to proceed.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in clients who are being treated for shock. What intervention should be specified in the client's plan of care while the client is ventilated?
Performing frequent oral care
Maintaining the client in a supine position
Suctioning the client every 15 minutes unless contraindicated
Administering prophylactic antibiotics, as prescribed
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
Blood urea nitrogen (BUN) level
Urine specific gravity
Alkaline phosphatase level
Creatinine level
Serum albumin level
An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock?
Apply an antibiotic ointment to the client's mucous membranes, as prescribed.
Perform passive range-of-motion exercises unless contraindicated.
Initiate total parenteral nutrition (TPN).
Remove invasive devices as soon as they are no longer needed.
