Chapter 37 Shock States Flashcards
1) A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock?
1. Cardiogenic
2. Hypovolemic
3. Distributive
4. Obstructive
Answer: 2
Explanation: 1. Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock.
2. Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority.
3. Distributive shock, particularly septic shock, is a potential complication for patients with burn injury, and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.
4. Depending on other injuries, the patient with burns may develop obstructive shock, but this is not the nurse’s highest priority in emergent care.
2) A nurse is providing care to a patient with progressive shock. Which patient problem is characteristic of this stage and is priority in guiding the selection of interventions for this patient?
1. The patient’s airway is often compromised.
2. Perfusion of oxygen and nutrients to tissues is insufficient.
3. The patient experiences maximal physiologic and psychologic stress in this stage.
4. Skin integrity continues to be impaired
Answer: 2
Explanation: 1. Without additional assessment findings, it is not possible to determine if this patient’s airway is compromised.
2. Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority problem for all patients in shock.
3. Undoubtedly this patient is experiencing stress, but this is not the highest priority problem.
4. This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.
3) A patient was admitted to the emergency department for treatment of a severe infection. Which traditional assessment would raise the nurse’s concern that this patient may be developing shock?
1. Hot, dry skin
2. Respiratory rate 11
3. Pulse rate 118 and weak
4. Anxiety
Answer: 3
Explanation: 1. Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection.
2. Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system.
3. Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases.
4. Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.
4) A patient was admitted to the emergency department for treatment of severe infection. Which objective parameters would increase the nurse’s concern that shock is developing?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Serum lactate level is 5.4 mmol/L.
2. Base deficit is −9 mmol/L.
3. SvO2 is 68%.
4. pHi is 6.9.
5. Arterial pH is 7.38.
Answer: 1, 2, 4
Explanation: 1. Lactate is the metabolic by-product of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least in part, on anaerobic metabolism rather than the normal aerobic metabolism.
2. This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation.
3. Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues.
4. Low mucosal pH indicates development of acidosis.
5. This is a normal arterial pH.
5) A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient’s mental status?
1. Temporarily discontinue the drip and assess mental status within a few minutes.
2. Temporarily discontinue the drug and plan to assess mental status in an hour.
3. Use “train of four” testing while the medication is still infusing.
4. This assessment will have to wait until the sedating drug is no longer needed.
Answer: 1
Explanation: 1. Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drug’s discontinuation.
2. Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid.
3. “Train of four” testing is used when the patient is receiving neuromuscular blocking agents.
4. Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed.
6) A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive?
1. The patient complains of a severe headache.
2. The patient’s urine output has dropped.
3. The patient begins to shiver.
4. The patient develops a cough.
Answer: 3
Explanation: 1. Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia.
2. Decreased urine output is not associated with treatment for hyperthermia.
3. Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified.
4. Development of a cough is not associated with treatment for hyperthermia.
7) The nurse is evaluating a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement?
1. Temperature of 97.8°F
2. Heart rate of 70 beats/min
3. Resistance to ventilator-assisted breaths
4. Pink tone to the skin
Answer: 2
Explanation: 1. Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic.
2. Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement.
3. Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status.
4. Peripheral vasodilation produces a pink skin tone, so this finding does not indicate improvement.
8) An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse’s priority intervention?
1. Benadryl (diphenhydramine) 50 mg intravenously
2. Oxygen at 3 liters via nasal cannula
3. Epinephrine 1:1000 0.5 mg sq
4. Normal saline at 150 mL/hr
Answer: 3
Explanation: 1. Administration of diphenhydramine is appropriate but is not the initial therapy.
2. Oxygen is administered according to pulse oximetry readings.
3. The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention.
4. After experiencing anaphylaxis, the patient will likely be hospitalized and given IV fluids. This is not the immediate priority.
9) A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention?
1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open.
2. Stop the infusion and place an intermittent infusion cap on the IV access device.
3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion.
4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient’s response.
Answer: 4
Explanation: 1. Abrupt withdrawal of this medication is not indicated.
2. Abrupt withdrawal of this drug is not indicated.
3. The infusion rate should not be abruptly lowered.
4. The nurse should decrease the infusion slowly, while monitoring the patient’s response. This is the only response that does not result in abrupt withdrawal of the medication
10) A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Persistent hypotension
2. Heart rate 118
3. Development of a bundle branch block
4. Drop in urine output
5. Mottling of extremities
Answer: 2, 3, 4, 5
Explanation: 1. The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough of the drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring.
2. Tachycardia can be an adverse effect of dopamine.
3. Aberrant cardiac conduction may indicate an adverse drug effect is occurring.
4. Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidneys will cause decrease in urine output.
5. Mottling of extremities indicates peripheral ischemia.
