Chapter 8 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 8

Question 1

Type: MCMA

What will the nurse identify as symptoms of hypovolemic shock in a patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Temperature of 97.6F (36.4C)

2. Restlessness

3. Decrease in blood pressure of 20 mm Hg when the patient sits up

4. Capillary refill time greater than 3 seconds

5. Sinus bradycardia of 55 beats per minute

Correct Answer: 2,3,4

Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate.

Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status.

Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock.

Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced.

Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 2

Type: MCSA

Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock?

1. Serum sodium of 130 mEq/L (130 mmol/L)

2. Metabolic acidosis validated by arterial blood gases

3. Serum lactate of 3 mmol/L

4. SvO2 greater than 80%

Correct Answer: 2

Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced.

Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion.

Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock.

Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 3

Type: MCSA

The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with:

1. Decreased cardiac output

2. Severe constipation, causing watery diarrhea

3. Ascites

4. Syndrome of inappropriate ADH (SIADH)

Correct Answer: 3

Rationale 1: Although ECG changes reflect the effectiveness of the hearts pumping when circulating the blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from either blood or fluid losses within the intravascular system.

Rationale 2: Severe constipation does not affect the circulating blood volume.

Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock.

Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 4

Type: MCSA

Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction?

1. Strong bounding pulse with deep red coloring

2. Pale, cool extremities with decreased pulses

3. Increased venous engorgement with strong pulses

4. Faster than normal capillary refill time

Correct Answer: 2

Rationale 1: An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and is not present with increased peripheral resistance and vasoconstriction.

Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply.

Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance.

Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 5

Type: MCSA

Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding?

1. 200 mL of normal saline (NS) per hour for 5 hours

2. A liter of Ringers lactate (RL) over 15 minutes

3. Two liters of D5W over half an hour

4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour

Correct Answer: 2

Rationale 1: This is not an adequate amount of fluid replacement.

Rationale 2: The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution.

Rationale 3: This is a hypotonic solution and would not help with fluid resuscitation.

Rationale 4: This is a hypotonic solution and would not help with fluid resuscitation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 6

Type: MCMA

Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fluid volume overload

2. Renal insufficiency

3. Cerebral ischemia

4. Gastric stress ulcer

5. Pulmonary edema

Correct Answer: 2,3

Rationale 1: Fluid volume overload is not an identified complication of hypovolemic shock.

Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia.

Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia.

Rationale 4: Although physiologic stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock.

Rationale 5: Pulmonary edema is not an identified complication of hypovolemic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 7

Type: MCSA

The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions:

1. Move quickly into the interstitial spaces and can cause third spacing

2. Stay longer to expand the intravascular space but deplete intracellular fluid levels

3. Do not stay in the intravascular space long enough to expand the circulating blood volume

4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low

Correct Answer: 3

Rationale 1: Hypotonic solutions do not cause third spacing.

Rationale 2: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume.

Rationale 3: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume.

Rationale 4: The bore size of the needle does not affect the displacement or shifting of fluids.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 8

Type: MCSA

The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication?

1. Hemorrhagic shock

2. Hypothermia

3. Sepsis

4. Cardiogenic shock

Correct Answer: 2

Rationale 1: Hemorrhagic shock is caused by a loss of cells or blood volume and is not a result of infusing fluids too quickly.

Rationale 2: Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them.

Rationale 3: Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid being administered.

Rationale 4: Cardiogenic shock results from poor ventricular functioning, not from the temperature of the intravenous fluids being administered too rapidly.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 9

Type: MCSA

Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient?

1. CVP = 8 mm Hg

2. MAP = 45 mm Hg

3. Urinary output of 0.1 mL/kg/hr

4. Hct = 54%

Correct Answer: 1

Rationale 1: A CVP reading of 8 mm Hg is within normal range and rehydration has been restored.

Rationale 2: The mean arterial pressure (MAP) should be between 60 to 70 mm Hg as evidence of positive fluid resuscitation efforts.

Rationale 3: Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume.

Rationale 4: Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid-to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 10

Type: MCSA

A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock?

1. Hypovolemic

2. Cardiogenic

3. Anaphylactic

4. Obstructive

Correct Answer: 2

Rationale 1: Pulmonary edema would not be present in hypovolemic shock.

Rationale 2: In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema.

Rationale 3: Pulmonary edema would not be present in anaphylactic shock.

Rationale 4: Pulmonary edema would not be present in obstructive shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-1: Identify the categories of shock.

Question 11

Type: MCMA

A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sepsis

2. Spinal cord injury

3. Anaphylaxis

4. Hemorrhage

5. Pulmonary embolism

Correct Answer: 1,2,3

Rationale 1: One etiology of distributive shock is sepsis.

Rationale 2: One etiology of distributive shock is spinal cord injury.

Rationale 3: One etiology of distributive shock is anaphylaxis.

Rationale 4: Hemorrhage is not an etiology of distributive shock.

Rationale 5: Pulmonary embolism is not an etiology of distributive shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-1: Identify the categories of shock.

Question 12

Type: MCMA

The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Age 80

2. History of atrial fibrillation

3. Bacteremia

4. T3 spinal cord injury

5. Latex allergy

Correct Answer: 1,2

Rationale 1: Advanced age increases the risk for development of pulmonary emboli, which is one cause of obstructive shock.

Rationale 2: Atrial fibrillation increases the risk for developing pulmonary emboli, which is one cause of obstructive shock.

Rationale 3: Bacteremia increases a patients risk of developing septic shock and not obstructive shock.

Rationale 4: A spinal cord injury increases the risk for developing distributive shock and not obstructive shock.

Rationale 5: A latex allergy increases the risk for developing distributive shock and not obstructive shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-1: Identify the categories of shock.

Question 13

Type: MCSA

A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because:

1. The release of histamine causes vasodilation with plasma leakage.

2. Sympathetic innervation is interrupted.

3. Microorganisms overwhelm the vascular system.

4. Parasympathetic innervation functions are unopposed.

Correct Answer: 1

Rationale 1: In an anaphylactic reaction leading to distributive shock, the release of histamine causes vasodilation with plasma leakage. Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation, reduced reload, and reduced cardiac output.

Rationale 2: Sympathetic innervation is not interrupted in an anaphylactic reaction.

Rationale 3: Microorganisms do not overwhelm the vascular system in an anaphylactic reaction.

Rationale 4: Parasympathetic innervation functioning unopposed is not a characteristic of an anaphylactic reaction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 8-1: Identify the categories of shock.

Question 14

Type: MCSA

A patient is diagnosed with cardiac tamponade. When planning care, the nurse will include interventions to address which type of shock?

1. Obstructive

2. Hypovolemic

3. Distributive

4. Cardiogenic

Correct Answer: 1

Rationale 1: Cardiac tamponade can lead to obstructive shock.

Rationale 2: Cardiac tamponade will not lead to hypovolemic shock.

Rationale 3: Cardiac tamponade will not lead to distributive shock.

Rationale 4: Cardiac tamponade will not lead to cardiogenic shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8-1: Identify the categories of shock.

Question 15

Type: MCSA

The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock?

1. Cardiogenic

2. Hypovolemic

3. Distributive

4. Obstructive

Correct Answer: 1

Rationale 1: One etiology of cardiogenic shock is a myocardial infarction.

Rationale 2: Acute myocardial infarction does not cause hypovolemic shock.

Rationale 3: Acute myocardial infarction does not cause distributive shock.

Rationale 4: Acute myocardial infarction does not cause obstructive shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 16

Type: MCSA

A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to:

1. Reduced cardiac output

2. Increased stroke volume

3. Reduced blood volume

4. Blood flow blocked in the pulmonary circulation

Correct Answer: 1

Rationale 1: In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion.

Rationale 2: In cardiogenic shock, stroke volume is decreased.

Rationale 3: There is not a reduction of blood volume in cardiogenic shock.

Rationale 4: There is not a blockage of blood flow through the pulmonary circulation in cardiogenic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 17

Type: SEQ

The nurse is explaining the mechanism of a pulmonary embolism to the family of a patient diagnosed with the disorder. Place in order the steps the nurse will use to instruct the family about this disease process.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Blood clot causes backup of blood in the right ventricle.

Choice 2. Blood clot blocks blood to the left ventricle.

Choice 3. Left ventricle does not get enough blood to pump through the body.

Choice 4. Amount of blood the heart has to pump to the body drops.

Choice 5. Blood pressure drops.

Choice 6. Amount of blood going to the body drops.

Correct Answer: 1,2,3,4,5,6

Rationale 1: The obstruction caused by the pulmonary embolism increases the afterload of the right ventricle, causing right ventricular failure.

Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation to the left ventricle.

Rationale 3: Because blood flow from the pulmonary circulation is blocked, left ventricular preload drops.

Rationale 4: Because left ventricular preload is decreased, there is not enough blood in the heart to pump, causing decreased cardiac output.

Rationale 5: A lack of blood circulating will lead to hypotension.

Rationale 6: When the blood is backed up and is not being pumped into the general circulation, tissue perfusion is reduced.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Teaching and Learning

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 18

Type: MCSA

A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock?

1. Obstructive

2. Hypovolemic

3. Distributive

4. Cardiogenic

Correct Answer: 1

Rationale 1: Acute pericarditis and the development of fluid accumulation in the pericardial space can lead to the development of obstructive shock.

Rationale 2: Pericarditis is not a risk factor for the development of hypovolemic shock.

Rationale 3: Pericarditis is not a risk factor for the development of distributive shock.

Rationale 4: Pericarditis is not a risk factor for the development of cardiogenic shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 19

Type: MCMA

A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Recent bee sting

2. Ingestion of drugs

3. History of latex allergy

4. Recent diagnostic imaging tests

5. Recent myocardial infarction

Correct Answer: 1,2,3,4

Rationale 1: Venoms such as bee stings can trigger anaphylactic shock.

Rationale 2: Drugs can trigger anaphylactic shock.

Rationale 3: Latex can trigger anaphylactic shock.

Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock.

Rationale 5: Myocardial infarction is not a trigger for anaphylactic shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-2: Discuss the etiologies and pathophysiology of hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 20

Type: MCMA

During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Systolic blood pressure 82 mm Hg

2. Capillary refill 10 seconds

3. Crackles bilateral lung bases

4. Heart rate 55 and regular

5. Warm dry skin

Correct Answer: 1,2,3

Rationale 1: Hypotension is a manifestation of cardiogenic shock.

Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock.

Rationale 3: Crackles are a manifestation of cardiogenic shock.

Rationale 4: Bradycardia is not a manifestation of cardiogenic shock.

Rationale 5: Warm dry skin is not a manifestation of cardiogenic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 21

Type: MCSA

A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding?

1. Jugular vein distention

2. Dry mucous membranes

3. Poor skin turgor

4. Thirst

Correct Answer: 1

Rationale 1: Jugular vein distention is a manifestation of cardiogenic shock.

Rationale 2: The mucous membranes are not dry in cardiogenic shock.

Rationale 3: The skin turgor is not poor in cardiogenic shock.

Rationale 4: Thirst is not a manifestation of cardiogenic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 22

Type: MCMA

A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patients diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Elevated pulmonary arterial wedge pressure

2. Elevated central venous pressure

3. Elevated systemic vascular resistance index

4. Elevated mean arterial pressure

5. Elevated stroke volume

Correct Answer: 1,2,3

Rationale 1: This finding is consistent with pulmonary vascular congestion.

Rationale 2: This finding is consistent with fluid volume overload.

Rationale 3: This finding is consistent with pulmonary vascular congestion.

Rationale 4: This finding is not consistent with cardiogenic shock.

Rationale 5: This finding is not consistent with cardiogenic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 23

Type: MCMA

The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hypotension

2. Bradycardia

3. Warm dry skin

4. Abdominal cramps

5. Palpitations

Correct Answer: 1,2,3

Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes.

Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation.

Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands.

Rationale 4: Abdominal cramping is not a manifestation of neurogenic shock.

Rationale 5: Palpitations are not seen in neurogenic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 24

Type: MCSA

A patient is demonstrating signs of obstructive shock but the cause has yet to be determined. Which finding indicates the patient is experiencing a pulmonary embolism as the cause for obstructive shock?

1. Chest pain

2. Hypotension

3. Tachycardia

4. Oliguria

Correct Answer: 1

Rationale 1: Chest pain is a symptom associated with a massive pulmonary embolus.

Rationale 2: Hypotension is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus.

Rationale 3: Tachycardia is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus.

Rationale 4: Oliguria is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8-3: Compare and contrast the assessment findings in patients experiencing hypovolemic, cardiogenic, obstructive, and distributive shock.

Question 25

Type: MCMA

The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Dopamine

2. Norepinephrine

3. Dobutamine

4. Epinephrine

5. Phenylephrine

Correct Answer: 1,2,3,5

Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock.

Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock.

Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure.

Rationale 4: Epinephrine is not used in the treatment of cardiogenic shock.

Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 26

Type: MCSA

A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time?

1. Limit patient movement.

2. Prepare to administer crystalloids.

3. Administer phenylephrine as prescribed.

4. Administer atropine as prescribed.

Correct Answer: 4

Rationale 1: Limiting movement will not correct bradycardia in the patient with neurogenic shock.

Rationale 2: Crystalloids are used to correct vasodilation.

Rationale 3: Phenylephrine is used in the patient with neurogenic shock to correct hypotension.

Rationale 4: Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 27

Type: MCMA

A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer epinephrine 1:1000 intramuscularly.

2. Apply oxygen via face mask as prescribed.

3. Provide diphenhydramine 25 mg intravenous.

4. Administer vasopressin.

5. Prepare to administer antithrombolytic agents as prescribed.

Correct Answer: 1,2,3

Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular.

Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock.

Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects.

Rationale 4: Vasopressin is not used in the treatment of anaphylactic shock.

Rationale 5: Antithrombolytic agents are not used in the treatment of anaphylactic shock.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-4: Identify specific interventions for the management of each type of shock.

Question 28

Type: MCSA

A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective?

1. Blood pressure 110/68 mm Hg

2. Heart rate 110

3. Respiratory rate 12 and regular

4. Decreased peripheral pulses

Correct Answer: 1

Rationale 1: The expected effect of this medication is an increase in blood pressure.

Rationale 2: Phenylephrine does not increase the heart rate.

Rationale 3: Phenylephrine does not affect the respiratory rate.

Rationale 4: Decreased peripheral pulses is a side/toxic effect of this medication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8-5: Compare and contrast the vasoactive medications used in the management of shock.

Question 29

Type: FIB

A patient weighing 220 lbs is prescribed 10 mcg/kg/min of dopamine to improve cardiac output from cardiogenic shock. How many milligrams of dopamine will the patient receive in an hour?

Standard Text: Record your answer rounding to the nearest whole number.

Correct Answer: 60

Rationale : Determine the patients weight in kg by dividing 220 lbs by 2.2 or 100 kg. Then multiply the number of mcg of medication the patient is to receive per minute by 100 kg or 10 mcg 100 kg = 1,000 mcg. This is the dosage the patient will receive in 1 minute. To determine the amount of medication in 1 hour, multiply 1,000 mcg 60 = 60,000 mcg. Using the conversion 1 mg = 1,000 mcg, divide 60,000 mcg by 1,000 mcg to determine that the patient will receive 60 mg of dopamine in 1 hour.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-5: Compare and contrast the vasoactive medications used in the management of shock.

Question 30

Type: MCSA

Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock?

1. Reduced wheezing

2. Heart rate 55 and regular

3. Blood pressure 98/50 mm Hg

4. Respiratory rate 28

Correct Answer: 1

Rationale 1: An expected action for epinephrine is bronchodilation as evidenced by less wheezing.

Rationale 2: Epinephrine increases heart rate.

Rationale 3: Epinephrine increases blood pressure.

Rationale 4: Epinephrine lowers the respiratory rate. This respiratory rate indicates that epinephrine has not been effective.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8-5: Compare and contrast the vasoactive medications used in the management of shock.

Question 31

Type: MCMA

A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Decreased peripheral pulses

2. Drop in body temperature

3. Onset of paresthesias

4. Drop in blood pressure

5. Increased cardiac output

Correct Answer: 1,2,3

Rationale 1: At high doses of norepinephrine, decreased peripheral pulses indicates significant vasoconstriction.

Rationale 2: At high doses of norepinephrine, a drop in body temperature indicates significant vasoconstriction.

Rationale 3: At high doses of norepinephrine, paresthesias indicate significant vasoconstriction.

Rationale 4: This medication does not cause a drop in blood pressure.

Rationale 5: An increase in cardiac output is an expected effect of this medication and does not indicate significant vasoconstriction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8-5: Compare and contrast the vasoactive medications used in the management of shock.

Question 32

Type: MCSA

A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication?

1. Provide the vasopressin infusion in addition to a norepinephrine infusion.

2. Infuse through a peripheral line.

3. Utilize a rapid infuser.

4. Administer with 0.9% normal saline.

Correct Answer: 1

Rationale 1: The dose of 0.03 units/min is usually added to a norepinephrine infusion.

Rationale 2: This medication should always be administered via an infusion pump.

Rationale 3: A rapid infuser is used to deliver large amounts of warmed crystalloid or blood to a patient over a short period of time. It is not used for medication administration.

Rationale 4: This medication does not need to be administered with 0.9% normal saline.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8-5: Compare and contrast the vasoactive medications used in the management of shock.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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