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Ch 14 Shock and multiple organ dysfunction syndrome
Terms in this set (40)
A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the
following statements best describes the pathophysiology of this patients health problem?
A) Blood is shunted from vital organs to peripheral areas of the body.
B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care,
the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following
A) Fluid volume circulating in the blood vessels decreases.
B) There is an uncontrolled increase in cardiac output.
C) Blood pressure regulation becomes irregular.
D) The patient experiences tachycardia and a bounding pulse.
The emergency nurse is admitting a patient 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
A) Increased urine output
B) Decreased heart rate
C) Hyperactive bowel sounds
D) Cool, clammy skin
The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following
injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order
the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal
saline, which crystalloid fluid is commonly used to treat hypovolemic shock?
A) Lactated Ringers
D) 3% NaCl
A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform
the nurses care planning during the administration of a vasoactive drug?
A) The drug should be discontinued immediately after blood pressure increases.
B) The drug dose should be tapered down once vital signs improve.
C) The patient should have arterial blood gases drawn every 10 minutes during treatment.
D) The infusion rate should be titrated according the patients subjective sensation of adequate
A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a
neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that
that patient is probably experiencing?
A) Anaphylactic shock
B) Neurogenic shock
C) Septic shock
D) Hypovolemic shock
The intensive care nurse caring for a patient in shock is planning assessments and interventions related
to the patients nutritional needs. What physiologic process contributes to these increased nutritional
A) The use of albumin as an energy source by the body because of the need for increased adenosine
B) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased
C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements
D) The increase in GI peristalsis during shock and the resulting diarrhea
The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical
unit. The medical nurse is aware that shock affects many organ systems and that nursing management of
the patient will focus on what intervention?
A) Reviewing the cause of shock and prioritizing the patients psychosocial needs
B) Assessing and understanding shock and the significant changes in assessment data to guide the plan
C) Giving the prescribed treatment, but shifting focus to providing family time as the patient is
unlikely to survive
D) Promoting the patients coping skills in an effort to better deal with the physiologic changes
When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient
will develop complications of shock. How can the nurse best achieve this goal?
A) Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping.
B) Keep the physician updated with the most accurate information because in cases of shock the nurse
often cannot provide relevant interventions.
C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on
blood pressure and skin temperature.
D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and
then provide rapid assessment.
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction
syndrome (MODS). The nurses plan of care should include which of the following interventions?
A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the
prognosis is good
B) Encouraging the family to leave the hospital and to take time for themselves as acute care of
MODS patients may last for several months
C) Promoting communication with the patient and family along with addressing end-of-life issues
D) Discussing organ donation on a number of different occasions to allow the family time to adjust to
The acute care nurse is providing care for an adult patient 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 the ADH during hypovolemic
A) Increased hunger
B) Decreased thirst
C) Decreased urinary output
D) Increased capillary perfusion
The nurse is caring for a patient whose progressing infection places her at high risk for shock. What
assessment finding would the nurse consider a potential sign of shock?
A) Elevated systolic blood pressure
B) Elevated mean arterial pressure (MAP)
C) Shallow, rapid respirations
You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who
is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention,
for what sign would you teach the new nurse to monitor the patient?
C) Coffee ground emesis
The nurse is caring for a patient in the ICU whose condition is deteriorating. The nurse receives orders
to initiate an infusion of dopamine. What would be the priority assessment and interventions specific to
the administration of vasoactive medications?
A) Frequent monitoring of vital signs, monitoring the central line site, and providing accurate drug
B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient
C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema
D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing early discharge
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The
nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased
bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary
A) The patient is in the compensatory stage of shock.
B) The patient is in the progressive stage of shock.
C) The patient will stabilize and be released by tomorrow.
D) The patient is in the irreversible stage of shock.
The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in
the irreversible stage of shock. What would be the most appropriate nursing intervention?
A) Provide opportunities for the family to spend time with the patient, and help them to understand the
irreversible stage of shock.
B) Inform the patients family immediately that the patient will likely not survive to allow the family
time to make plans and move forward.
C) Closely monitor fluid replacement therapy, and inform the family that the patient will probably
survive and return to normal life.
D) Protect the patients airway, optimize intravascular volume, and initiate the early rehabilitation
The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in
hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the
best choice for fluid replacement for this patient is what?
A) 5% albumin because it is inexpensive and is always readily available
B) Dextran because it increases intravascular volume and counteracts coagulopathy
C) Whatever fluid is most readily available in the clinic, due to the nature of the emergency
D) Lactated Ringers solution because it increases volume, buffers acidosis, and is the best choice for
patients with liver failure
The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor
vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What
would be the main challenge in meeting this patients elevated energy requirements during prolonged
A) Loss of adipose tissue
B) Loss of skeletal muscle
C) Inability to convert adipose tissue to energy
D) Inability to maintain normal body mass
The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The
nurse understands that the patients heart is pumping an inadequate supply of oxygen to the tissues. For
what health problem should the nurse assess?
B) Increase in blood pressure
C) Increase in heart rate
D) Decrease in oxygen demands
The nurse is caring for a patient admitted with cardiogenic shock. The patient 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 patient?
A) It promotes coping and slows catecholamine release.
B) It stimulates the patient so he or she is more alert.
C) It decreases gastric secretions.
D) It dilates the blood vessels.
The nurse is providing care for a patient 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 is a compensatory mechanism to increase cardiac output during
A) Third spacing of fluid
D) Gastric hypermotility
The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or
symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction?
Select all that apply.
A) Drop in systolic blood pressure of 40 mm Hg from baselines
B) Hypotension that responds to bolus fluid resuscitation
C) Exaggerated response to vasoactive medications
D) Serum lactate >4 mmol/L
E) Mean arterial pressure (MAP) of 65 mm Hg
An adult patient 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 patient. What aspect of his care should be prioritized by the home health nurse?
A) Providing supervision to home health aides in providing necessary patient care
B) Assisting the patient and family to identify and mobilize community resources
C) Providing ongoing medical care during the familys rehabilitation phase
D) 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. Which of the following interventions is used in all types of shock?
A) Aggressive hypoglycemic control
B) Administration of hypertonic IV fluids
C) Early provision of nutritional support
D) Aggressive antibiotic therapy
In all types of shock, nutritional demands increase rapidly as the body depletes its stores of glycogen. Enteral nutrition is the preferred method of meeting these increasing energy demands. What is the basis for enteral nutrition being the preferred method of meeting the bodys needs?
A) It slows the proliferation of bacteria and viruses during shock.
B) It decreases the energy expended through the functioning of the GI system.
C) It assists in expanding the intravascular volume of the body.
D) It promotes GI function through direct exposure to nutrients.
The ICU nurse is caring for a patient with multiple organ dysfunction syndrome (MODS) due to shock. What nursing action should be prioritized at this point during care?
A) Providing information and support to family members
B) Preparing the family for a long recovery process
C) Educating the patient regarding the use of supportive fluids
D) Facilitating the rehabilitation phase of treatment
A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to
developing fluid replacement complications. For what signs and symptoms should the nurse monitor the
patient? Select all that apply.
B) Difficulty breathing
C) Cardiovascular overload
D) Pulmonary edema
When circulatory shock occurs, there is massive vasodilation causing pooling of the blood in the
periphery of the body. An ICU nurse caring for a patient in circulatory shock should know that the
pooling of blood in the periphery leads to what pathophysiological effect?
A) Increased stroke volume
B) Increased cardiac output
C) Decreased heart rate
D) Decreased venous return
A team of nurses are reviewing the similarities and differences between the different classifications of
shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply.
A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The
child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they
were waiting for the boys mother to get off work. Which of the following would lead the nurse to
suspect that the boy is experiencing anaphylactic shock?
A) Rapid onset of acute hypertension
B) Rapid onset of respiratory distress
C) Rapid onset of neurologic compensation
D) Rapid onset of cardiac arrest
The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety
medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic
B) Cool, moist skin
D) Signs of sympathetic stimulation
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in
shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary
goal of this aspect of treatment?
A) To prevent the formation of infarcts of emboli
B) To limit stroke volume and cardiac output
C) To prevent pulmonary and peripheral edema
D) To maintain adequate mean arterial pressure
The ICU nurse caring for a patient in shock is administering vasoactive medications as per orders. The
nurse should know that vasoactive medications should be administered in what way?
A) Through a central venous line
B) By a gravity infusion IV set
C) By IV push for rapid onset of action
D) Mixed with parenteral feedings to balance osmosis
The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For
what serious complication of treatment should the nurse monitor the patient?
B) Decreased oxygen consumption
C) Abdominal compartment syndrome
D) Decreased serum osmolality
Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable
progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion
declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would
indicate to the nurse that end-organ damage may be occurring?
A) Urinary output increases
B) Skin becomes warm and dry
C) Adventitious lung sounds occur in the upper airway
D) Heart and respiratory rates are elevated
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a
really bad allergic reaction to peanuts after trading lunches with a peer. The triage nurses rapid
assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse
A) Establishing central venous access and beginning fluid resuscitation
B) Establishing a patent airway and beginning cardiopulmonary resuscitation
C) Establishing peripheral IV access and administering IV epinephrine
D) Performing a comprehensive assessment and initiating rapid fluid replacement
A patient 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 patients care?
A) Communicate clearly and frequently with the patients family.
B) Taper down interventions slowly when the prognosis worsens.
C) Transfer the patient to a subacute unit when recovery appears unlikely.
D) Ask the patients family how they would prefer treatment to proceed.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients
who are being treated for shock. What intervention should be specified in the patients plan of care while
the patient is ventilated?
A) Performing frequent oral care
B) Maintaining the patient in a supine position
C) Suctioning the patient every 15 minutes unless contraindicated
D) Administering prophylactic antibiotics, as ordered
A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite
aggressive interventions, the patients mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse
should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that
A) Blood urea nitrogen (BUN) level
B) Urine specific gravity
C) Alkaline phosphatase level
D) Creatinine level
E) Serum albumin level
An immunocompromised older adult has developed a urinary tract infection and the care team
recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and
septic shock. What action should the nurse perform to reduce the patients risk of septic shock?
A) Apply an antibiotic ointment to the patients mucous membranes, as ordered.
B) Perform passive range-of-motion exercises unless contraindicated
C) Initiate total parenteral nutrition (TPN)
D) Remove invasive devices as soon as they are no longer needed
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