Chap 69: Shock and Multi-organ Dysfunction Syndrome

Question 1

A patient is treated in the emergency department for shock following an automobile accident. The nurse knows that shock is a clinical syndrome in which cellular dysfunction and organ failure occur primarily as a result of which of the following conditions?

a. Hypotension
b. Loss of blood
c. Severe infection
d. Impaired tissue perfusion

Answer 1

ANS: D
Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism, resulting in an imbalance between the supply of and demand for oxygen and nutrients.

Question 2

Which hemodynamic results would the nurse anticipate in a patient who is in cardiogenic shock?

a. Increased heart rate (HR), blood pressure (BP), and cardiac output (CO)
b. Increased HR, decreased BP and CO
c. Decreased HR, BP, and CO
d. Decreased HR, increased BP and CO

Answer 2

ANS: B

A patient in cardiogenic shock would have an increased HR and a decreased BP and CO.

Question 3

A patient with hypovolemic shock has a urinary output of 15 mL/hour. What does the nurse understand is the compensatory physiological mechanism that leads to altered urinary output?

a. Release of aldosterone, which increases serum osmolarity, causing release of antidiuretic hormone (ADH)
b. Movement of interstitial fluid to the intravascular space, increasing renal blood flow
c. Activation of the sympathetic nervous system, causing vasodilation of the renal arteries
d. -Adrenergic receptor stimulation that causes increased CO as a result of increased HR and myocardial contractility

Answer 3

ANS: A
The release of aldosterone and ADH leads to the decrease in urinary output by increasing the reabsorption of sodium and water in the renal tubules.

Question 4

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on observing which of the following findings?

a. Cold, mottled extremities
b. Restlessness and apprehension
c. An HR of 120 beats/min and cool, clammy skin
d. A systolic BP less than 90 mm Hg and a widening pulse pressure

Answer 4

ANS: B

Restlessness and apprehension are typical during the compensatory stage of shock.

Question 5

A patient has been admitted with a spinal cord injury. The nurse anticipates neurogenic shock with a spinal cord injury at which level of the spine?

a. T4
b. T6
c. T8
d. L2

Answer 5

ANS: A

Neurogenic shock can occur with a spinal cord injury at the level of T5 or above.

Question 6

The nurse determines that the patient in shock has progressed beyond the compensated stage when laboratory tests reveal which of the following results?

a. Increased blood glucose levels
b. Increased serum sodium levels
c. Decreased serum calcium levels
d. Increased serum potassium levels

Answer 6

ANS: D
Decreased potassium is found in early shock because of increased secretion of aldosterone, causing renal excretion of potassium; however, when the patient’s shock progresses beyond the compensated stage, the potassium increases because cellular death liberates intracellular potassium.

Question 7

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock based on which of the following findings?

a. Bradycardia
b. Hypotension
c. Cool, clammy skin
d. A subnormal body temperature

Answer 7

ANS: A
The normal sympathetic response to shock and hypotension is an increase in HR. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock.

Question 8

When caring for a patient in shock, the nurse notifies the physician of the patient’s deteriorating status when the patient’s arterial blood gas results include which of the following findings?

a. pH 7.48, partial pressure of arterial carbon dioxide (PaCO2) 33 mm Hg
b. pH 7.33, PaCO2 30 mm Hg
c. pH 7.50, PaCO2 50 mm Hg
d. pH 7.38, PaCO2 45 mm Hg

Answer 8

ANS: B
The patient’s low pH despite a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock. Rapid changes in therapy are needed

Question 9

During the initial management of any patient in shock, the nurse knows that which of the following is an appropriate intervention?

a. Fluid resuscitation
b. Administration of vasopressors
c. Administration of inotropic agents
d. Administration of high-flow oxygen

Answer 9

ANS: C

An inotropic agent (e.g., dobutamine [Dobutrex]) is often added to offset the decrease in stroke volume.

Question 10

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and CO. The nurse anticipates the administration of which of the following medications?

a. Nitroglycerine (Tridil)
b. Dobutamine
c. Norepinephrine (Levophed)
d. Sodium nitroprusside (Nipride)

Answer 10

ANS: B
When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance and improve tissue perfusion.

Question 11

Which of the following nursing interventions prevents the development of shock?

a. Routine checking of stools for occult blood
b. Keeping patients warm to prevent chilling or shivering
c. Identifying situations in which patients are at risk for shock
d. Frequent monitoring of patient status to detect compensatory changes

Answer 11

ANS: C
To prevent shock, the nurse needs to identify patients at risk. In general, patients who are older, those with debilitating illnesses, and those who are immunocompromised are at an increased risk. Any person who sustains surgical or accidental trauma is at high risk for shock resulting from hemorrhage, spinal cord injury, and other conditions. Any patient who is at risk for decreased oxygen delivery or tissue hypoxia is also at risk for the development of shock.

Question 12

A patient stung by a bee develops severe respiratory distress and is in anaphylactic shock. Which medication will the nurse prepare to administer immediately?

a. Epinephrine (Adrenalin)
b. Crystalloid fluids
c. Dexamethasone (Decadron)
d. Diphenhydramine (Benadryl)

Answer 12

ANS: A

Epinephrine is the medication of choice to treat anaphylactic shock.

Question 13

Which type of shock does the nurse suspect with a patient who is short of breath and has wheezes, rhinitis, and stridor?

a. Cardiogenic shock
b. Neurogenic shock
c. Anaphylactic shock
d. Septic shock

Answer 13

ANS: C
A patient in anaphylactic shock exhibits shortness of breath, wheezes, rhinitis, and stridor, and often has swelling of the lips and tongue

Question 14

A patient with multiple traumas is brought to the emergency department. The nurse initiates two peripheral intravenous (IV) sites and begins fluid resuscitation with which of the following fluids?

a. Dextran
b. 0.9% saline
c. 3.0% saline
d. Dextrose 5% in water in one-half normal saline

Answer 14

ANS: B

Fluid resuscitation is accomplished by using normal saline, that is, 0.9% saline.

Question 15

The nurse evaluates that fluid resuscitation for a patient in shock is effective on observing which of the following findings?

a. Urinary output is 1 mL/kg/hour.
b. Pulse pressure becomes narrower.
c. Pulmonary artery occlusive pressure decreases.
d. BP is within the patient’s normal range.

Answer 15

ANS: A

A urinary output of at least 0.5 mL/kg/hour indicates adequate renal perfusion, which is a good indicator of CO

Question 16

The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. What will the nurse obtain in preparation for the patient’s arrival?

a. A litre of lactated Ringer’s solution
b. 500 mL of 5% albumin
c. Two 14-gauge IV catheters
d. A retention catheter

Answer 16

ANS: C
A patient with multiple traumas may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for two large-bore IV lines to administer normal saline.

Question 17

Norepinephrine has been ordered for the patient in hypovolemic shock. Before administering the medication, the nurse ensures that which of the following has occurred?

a. The patient’s HR is less than 100 beats/min.
b. The patient’s urinary output is within the normal range.
c. The patient has received adequate fluid replacement.
d. The patient is not receiving additional sympathomimetic drugs.

Answer 17

ANS: C
If vasoconstrictors are given to a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion, so the nurse needs to ensure that the patient has received adequate fluid replacement before administration.

Question 18

When caring for a patient in cardiogenic shock, the nurse evaluates the status of the patient, recognizing that which of the following is the goal of care?

a. To lower the HR and control dysrhythmias
b. To lower the BP and respiratory rate
c. To improve oxygen exchange and increase urinary output
d. To decrease cardiac workload and increase systemic perfusion

Answer 18

ANS: D
For a patient in cardiogenic shock, the overall goal is to restore blood flow to the myocardium by restoring the balance between oxygen supply and demand by decreasing the cardiac workload and increasing systemic perfusion.

Question 19

While evaluating the effects of treatment in a patient in shock, the nurse finds that the patient has orthostatic hypotension. This finding indicates a need for which of the following treatments?

a. Additional fluid replacement
b. Administration of antibiotics
c. Administration of an inotropic drug
d. Administration of supplemental oxygen

Answer 19

ANS: A

A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions.

Question 20

What is an appropriate nursing intervention for a patient in shock with the nursing diagnosis of fear related to perceived threat of death?

a. Arrange for a member of the clergy to visit the patient.
b. Ask the physician to prescribe a sedative for the patient.
c. Provide the patient with as much privacy with the family as possible.
d. Place the patient’s call bell where it can be easily reached.

Answer 20

ANS: D

The patient who is fearful should feel that the nurse is immediately available if needed

Question 21

Which of the following is a patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia?

a. Normal mentation
b. Increase in BP
c. Verbalization of reduced anxiety
d. Reduction in heart and respiratory rates

Answer 21

ANS: A

Restoration of normal mentation is evidence that the patient has improved and that hypovolemia has been eliminated

Question 22

When caring for the patient with cardiogenic shock and possible multiple-organ dysfunction syndrome (MODS), what information obtained by the nurse will help confirm the diagnosis of MODS?

a. The patient has crackles throughout both lung fields.
b. The patient complains of crushing chest pain at a level of 8 on a 10-point scale.
c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities and weak pedal pulses.

Answer 22

ANS: C

The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure.

Question 23

In the diagnostic criteria for sepsis, a patient is considered to have a fever if the temperature is higher than which of the following?

a. 37.7°C
b. 38.0°C
c. 38.3°C
d. 38.5°C

Answer 23

ANS: C

In the diagnostic criteria for sepsis, a patient is considered to have a fever if the temperature is higher than 38.3°C

Question 24

When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?

a. BP 88/56 mm Hg
b. Apical pulse 110 beats/min
c. Urinary output 15 mL for 2 hours
d. Arterial oxygen saturation 90%

Answer 24

ANS: C
The best data for gathering the adequacy of CO are those that provide information about end-organ perfusion such as urinary output by the kidneys

Question 25

25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, what should the nurse assess?
    a. Stool guaiac and bowel sounds
    b. Lung sounds and oxygenation status
    c. Serum creatinine and urinary output
    d. Serum bilirubin levels and skin colour

Answer 25

ANS: B
The respiratory system is usually the system to show signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system.

Question 26

Which hemodynamic results would the nurse expect to assess in a patient who is in neurogenic shock?

a. Increased HR, decreased BP and pulse pressure
b. Increased HR, BP, and pulse pressure
c. Decreased HR, increased BP and pulse pressure
d. Decreased HR, BP, and pulse pressure

Answer 26

ANS: D

A patient in neurogenic shock would have a decreased HR, BP, and pulse pressure.