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A patient experiences a myocardial infarction (MI). The nurse closely monitors the patient for complications and recognizes that hypotension is a warning sign of:
1. A secondary MI
2. Pulmonary edema
3. Cardiogenic shock
4. Fatal dysrhythmias
Answer: 3. Cardiogenic shock
One of the initial cardinal signs of cardiogenic shock after a myocardial infarction (MI) is a slow, steady drop in blood pressure. Hypotension after an MI may be an indirect sign of a secondary MI or a fatal dysrhythmia. Depending on the origin of pulmonary edema, patients may experience hypotension or hypertension.
When caring for a patient in acute septic shock, what should the nurse anticipate?
1. Infusing large amounts of intravenous (IV) fluids
2. Administering osmotic or loop diuretics
3. Administering IV diphenhydramine (Benadryl)
4. Assisting with insertion of a ventricular assist device (VAD)
Answer: 1. Infusing large amounts of intravenous (IV) fluids
Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. The administration of diuretics is inappropriate. Diphenhydramine may be used for anaphylactic shock, but would not be helpful with septic shock. VADs are useful for cardiogenic shock, not septic shock.
The primary health care provider prescribes antibiotics and vasopressors for a patient. Which type of shock does the nurse expect to be treating?
1. Septic shock
2. Cardiogenic shock
3. Neurogenic shock
4. Anaphylactic shock
Answer: 1. Septic shock
Septic shock occurs in response to infection. Therefore, antibiotics are prescribed for a patient with septic shock. Cardiogenic shock occurs when systolic or diastolic function of the heart is impaired. Sympathomimetic drugs are used for the treatment of cardiogenic shock. Injury to the spinal cord at the fifth thoracic vertebra or above causes neurogenic shock. Vasconstricting medications are prescribed to prevent vasodilation for a patient in septic shock. Anaphylactic shock is a life-threatening allergic reaction to a sensitizing substance. Antihistamines, bronchodilators, and corticosteroids are used in the treatment of anaphylactic shock.
A nurse caring for a patient with multiple organ dysfunction syndrome understands that the patient may be at increased risk of bleeding. What nursing interventions should the nurse perform to manage this patient? Select all that apply.
1. Observe bleeding
2. Decrease fluid intake
3. Provide enteral feedings
4. Administer platelets and clotting factors
5. Minimize traumatic interventions
Answer: 1, 4, 5
The patient with multiple organ dysfunction syndrome is at a risk of bleeding due to increased bleeding time, thrombocytopenia, and dysfunctional clotting process. The nursing interventions should be aimed at preventing potential bleeding and replacing factors being lost. The patient should be observed for frank or occult bleeding from potential sites. The factors like platelets and clotting factors should be replaced if deficient. Traumatic interventions such as intramuscular injections or multiple venipunctures should be avoided. Decreasing the fluid intake and providing enteral feedings will not help in minimizing hematological complications.
The nurse assesses a patient with multisystem organ dysfunction syndrome. What assessment finding is most indicative of deterioration?
1. Arterial PO2 of 95%
2. Pulse rate of 108 beats/min
3. Total urine output of 120mL over the past 8 hours
4. Auscultation of fine bilateral crackles and moist cough
Answer: 3. Total urine output of 120mL over the past 8 hours
A decrease in urine output to less than 30 mL/hr in an adult is an early indication of hypoperfusion to the kidneys, as well as other vital organs. This may or may not be accompanied by changes in vital signs. An arterial Po2 of 95%, a pulse rate of 108 beats/min, and auscultation of crackles and a moist cough may also be indications of early deterioration but are not as specific as a low urinary output in identifying deterioration.
Which medical emergency is caused by the failure of two or more organ systems?
1. Crush syndrome
2. Toxic shock syndrome
3. Multiple organ dysfunction syndrome (MODS)
4. Systemic inflammatory response syndrome (SIRS)
Answer: 3. Multiple organ dysfunction syndrome (MODS)
Multiple organ dysfunction syndrome is caused by the failure of two or more organ systems in an acutely ill patient. A crushing injury to the skeletal muscle causes crush syndrome, which is characterized by shock and renal failure. Bacterial toxins cause toxic shock syndrome, which is characterized by high fever, hypotension, and malaise. Systemic inflammatory response syndrome is a systemic inflammatory response caused by infection, ischemia, infarction, and injury.
The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning?
1. PaO2 60mmhHg
2. Blood pressure 100/56 mmHg
3. Urine output 260 mL in eight hours
4. Heart rate 96 beats per minute
Answer: 1. PaO2 60 mmHg
A PaO2 of 60 is below the normal 80 to 100 mm Hg. The patient experiencing cardiogenic shock will exhibit hypotension and tachycardia, and therefore a blood pressure of 100/56 mm Hg and heart rate of 96 would not apply. A urine output of 260 cc/8 hrs is borderline but not reportable without a continued trending pattern.
A patient is diagnosed with multiple organ dysfunction syndrome. While aggressive treatment is continued, the nurse suspects infection. What is the most appropriate action that the nurse should perform?
1. Discontinue the aggressive treatment
2. Reduce oxygen delivery to the patient
3. Wait for laboratory reports to confirm
4. Obtain a prescription for broad-spectrum antibiotic therapy
Answer: 4. Obtain a prescription for broad-spectrum antibiotic therapy
If an infection is suspected, broad-spectrum antibiotics should be started immediately to limit the infection. Aggressive treatment for infection control should be carried out in parallel. These patients are usually hypoxemic. Therefore, oxygen should be administered strictly as prescribed. Cultures can be sent, and based on the reports, specific antibiotics can be added.
When examining a patient in progressive stage of shock, which factors related to the gastrointestinal (GI) system should the nurse consider? Select all that apply.
1. Increased motility and peristalsis
2. Increased likelihood of GI ulcers
3. Increased ability to absorb nutrients
4. Increased risk of GI bleeding
5. Increased risk of bacterial migration from the GI tract to the blood stream.
Answer: 2, 4, 5
In the progressive stages of shock, the GI system gets affected by prolonged decreased tissue perfusion. As the blood supply to the GI tract is decreased, the normally protective mucosal barrier becomes ischemic. This ischemia predisposes the patient to ulcers and GI bleeding. It also increases the risk of bacterial migration from the GI tract to the blood. The decreased perfusion to the GI tract also results in a decreased ability to absorb nutrients, decreased motility, and slowed peristalsis.
The nurse is caring for a patient who has cardiogenic shock. Which medical diagnosis does the nurse suspect?
3. Myocardial infarction
4. Tension pneumothorax
Answer: 3. Myocardial infarction
Myocardial infarction may produce necrotic areas of cardiac tissue that lead to impaired contractility and decreased cardiac output. This may lead to a cardiogenic shock state. Hemorrhage may lead to a hypovolemic shock state, tension pneumothorax may lead to an obstructive shock state, and urosepsis may lead to a septic shock state.
The nurse reviews the plan of care for a patient with multisystem organ dysfunction syndrome. What is the most desirable outcome for the patient?
1. The patient will be free of signs and symptoms of sepsis
2. The patient will maintain a balanced fluid intake and output
3. The patient will experience enhanced overall well-being and mental rest
4. The patient will demonstrate improved perfusion and oxygenation of organ
Answer: 4. The patient will demonstrate improved perfusion and oxygenation of organs
The underlying pathophysiology of multisystem organ dysfunction syndrome (MODS) is a lack of perfusion to organs, resulting in tissue and/or organ hypoxia. Interventions to improve perfusion with fluids or medications improve patient outcomes. The outcomes listed in the other answer options are appropriate and desirable for the patient with MODS, but they are secondary to improved perfusion and oxygenation.
A patient's localized infection has progressed to the point where septic shock now is suspected. What medication is an appropriate treatment modality for this patient?
1. Insulin infusion
2. Intravenous (IV) administration of epinephrine
3. Aggressive IV crystalloid fluid resuscitation
4. Administration of nitrations and beta-adrenergic blockers
Answer: 3. Aggressive IV crystalloid fluid resuscitation
Patients in septic shock require large amounts of crystalloid fluid replacement. Epinephrine is indicated in anaphylactic shock, and insulin infusion is not normally necessary in the treatment of septic shock (but can be). Nitrates and β-adrenergic blockers are used most often in the treatment of patients in cardiogenic shock.
When managing hypoxemia in a patient with multiple organ dysfunction syndrome, what appropriate interventions should the nurse use to decrease oxygen demand? Select all that apply.
1. Sedate the patient
2. Administer analgesics.
3. Assist the patient to move around
4. Catheterize the patient
5. Initiate mechanical ventilation
Answer: 1, 2, 5
When managing hypoxemia in a patient with multiple organ dysfunction syndrome, decreasing the oxygen demand is very important for adequate tissue oxygenation. Sedation, providing analgesia, and mechanical ventilation are helpful in decreasing the oxygen demand of the tissues. Resting the patient should be preferred over ambulation or movement to limit the intake of oxygen. Catheterizing the patient may aid in monitoring the urine output, but does not help in conserving oxygen.
What laboratory finding fits with a medical diagnosis of cardiogenic shock?
1. Decreased liver enzymes
2. Increased white blood cells
3. Decreased red blood cells, hemoglobin, and hematocrit
4. Increased blood urea nitrogen (BUN) and serum creatinine levels
Answer: 4. Increased blood urea nitrogen (BUN) and serum creatinine levels
The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, while white blood cell levels typically do not increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.
When caring for a patient with multiple organ dysfunction syndrome, what treatment should the nurse anticipate for stress ulcer prophylaxis? Select all that apply.
4. Proton pump inhibitors
5. Calcium channel blockers
Answer: 1, 3, 4
The patient with multiple organ dysfunction syndrome is at risk of developing stress ulcers due to decreased peristalsis and mucosal ischemia. Antacids, sucralfate, and proton pump inhibitors are the appropriate treatment used for stress ulcer prophylaxis. Diuretics are used to treat fluid imbalance and improve renal function. Calcium channel blockers are used to treat cerebral vasospasms.
A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed-head injury. Which clinical manifestation warns the nurse that the patient's condition is progressing to multiple organ dysfunction syndrome?
1. Hypotension and dysrhythmias
2. Urine output less than 400mL/day
3. Alterations in level of consciousness
4. Decreased PaO2 with an increase in FiO2
Answer: 4. Decreased PaO2 with an increase in FiO2
Decreased PaO2 with an increase in FiO2 (refractory hypoxemia) is correct because the lungs are the first organ to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome. Hypotension and dysrhythmias can occur with hypovolemia and hypoxia without progressing to multiple organ dysfunction syndrome. Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome, when the kidneys become involved. Alteration in level of consciousness is probably already present with the closed head injury, and also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia, and not necessarily progress to multiple organ dysfunction syndrome.
When working in an acute medical setting, which patients should a nurse consider to be prone to a risk of developing septic shock? Select all that apply.
1. An 80-year-old with a compromised immune system
2. A 55-year-old with diabetes
3. A 45-year-old with heart failure
4. A 70-year-old with malnourishment
5. A 15-year-old with cold
6. A 20-year-old with headache
Answer: 1, 2, 3, 4
The patients who are at risk of developing septic shock include older adults who have a compromised immune system. It also includes patients with diabetes and heart failure due to a dysfunctional immune response. Malnourished patients are at risk, owing to their inadequate immune body components. Patients who are prone to cold and headache and have no other health-related illnesses do not have any risk of developing septic shock.
What is a manifestation of the irreversible stage of shock?
4. Alterations in the level of consciousness
Answer: 2. Areflexia
Areflexia or loss of reflexes is a manifestation of the irreversible stage of shock. The progressive state of shock is associated with delirium. Restlessness and altered levels of consciousness indicate that the patient is in the compensatory stage of shock.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?
1. Acute pain
2. Impaired tissue integrity
3. Decreased cardiac output
4. Ineffective tissue perfusion
Answer: 4. Ineffective tissue perfusion
The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. Ineffective tissue perfusion supersedes acute pain, impaired tissue integrity, and decreased cardiac output because circulation is a priority. Acute pain may occur, but is not a priority at this time. Tissue integrity is not impaired.
A nurse is examining a patient with anaphylactic shock due to an insect bite. What types of skin manifestations would the nurse expect to find? Select all that apply.
5. Cold, clammy skin
Answer: 2, 3, 4
Insect bites may cause allergic reactions and anaphylactic shock. The skin manifestations may include pruritus, flushing, and urticaria caused by massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. Pallor and cold, clammy skin changes are usually seen in cardiogenic, hypovolemic, and obstructive shock caused by decreased circulatory volume and tissue perfusion.
Which type of shock is associated with hyperglycemia, presence of pulmonary infiltrates in chest X-ray, and increased levels of blood urea nitrogen (BUN)?
Answer: 2. Cardiogenic
Increased blood levels of glucose and nitrogen, cardiac markers, and presence of pulmonary infiltrates are seen in cardiogenic shock. Increased blood levels of lactate, glucose, and positive blood cultures are signs of septic shock. Manifestations of obstructive shock are specific to the area or organ of obstruction. Electrolyte imbalances and decreased hemoglobin and hematocrit are seen in hypovolemic shock.
The health care provider prescribes a dose of dobutamine (Dobutrex) for a patient in cardiogenic shock due to myocardial infarction. What appropriate actions should the nurse perform for safely administering the medication? Select all that apply.
1. Monitor heart rate and blood pressure
2. Stop infusion if tachydysrhythmias develop
3. Always administer with sodium bicarbonate
4. Administer through a central line
5. Use a glass bottle for infusion
Answer: 1, 2, 4
Doubutamine is a sympathomimetic medication. When used in therapy with dobutamine, the patient's heart rate and blood pressure should be continuously monitored, as it may worsen hypotension, requiring the addition of a vasopressor. The infusion should be stopped if tachydysrhythmias develop. The administration through a central line is recommended, as infiltration leads to tissue sloughing. The drug should not be administered with sodium bicarbonate, as it can get deactivated. As dobutamine is not adsorbed in plastic containers, it is not necessary to administer the drug in glass bottles.
A patient diagnosed with multiple organ dysfunction syndrome is developing pulmonary edema. The nurse realizes that which factor is the cause of the edema?
1. Tissue hypoxia
2. Unregulated apoptosis
3. Microvascular coagulopathy
4. Uncontrolled systemic inflammation
Answer: 4. Uncontrolled systemic inflammation
During sepsis, early activation of immune cells is followed by down regulation of their activity, which leads to a state of immune deficiency and increased risk of superinfection. Proinflammatory mediators increase capillary permeability, resulting in edema in organs such as the lungs. This is why the patient is developing pulmonary edema. Evidence of tissue hypoxia will occur in the gastrointestinal tract and the brain first. Unregulated apoptosis is uncontrollable cellular death. Pulmonary edema is not a symptom of unregulated apoptosis. Microvascular coagulopathy will manifest as abnormal clotting factors and microembolism production.
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)?
1. Increased serum albumin
2. Decreased respiratory compliance
3. Increased gastrointestinal (GI) motility
4. Decreased blood urea nitrogen (BUN)/creatinine ratio
Answer: 2. Decreased respiratory compliance
Clinical manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism. Serum albumin is not increased, GI motility decreases in MODS, and the BUN/Creatinine ratio likely will increase.
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