Chapter 81 : Management of Clients with Shock and Multisystem Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 81 : Management of Clients with Shock and Multisystem Disorders

MULTIPLE CHOICE

1. Distributive shock is primarily due to

a.

a fluid shift from the vascular space.

b.

an increase in the size of the vascular space.

c.

inadequate circulating blood volume.

d.

inadequate pumping action of the heart.

ANS: B

Distributive shock is due to changes in blood vessel tone that increase the size of the vascular space without an increase in the circulating blood volume.

DIF: Knowledge/Remembering REF: p. 2155 OBJ: N/A

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. A client has been in a motor vehicle accident and sustained significant injuries. The client is in shock and is semi-conscious, but is restless and moaning. The family is concerned the client is in pain and demands the nurse administer ordered morphine. The priority action by the nurse is to

a.

check the clients oxygen saturation.

b.

give morphine as ordered, slowly.

c.

politely decline their request.

d.

reposition the client.

ANS: A

Restlessness must be evaluated carefully, because it can signify both hypoxia and pain. While trauma clients must have their pain attended to, nurses must use opioids cautiously because they cause hypotension, further exacerbating shock. The first action by the nurse should be to check on the clients oxygenation status. If the clients oxygenation status is stable, the nurse should try positioning and other comfort measures as allowed by the clients condition before using opioids. The nurse should not simply decline the familys request; the nurse needs to educate the family as to the concerns and continue to provide high-caliber care. When opioids are used, they should be given IV, in small amounts, and given slowly.

DIF: Analysis/Analyzing REF: p. 2178 OBJ: Assessment

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

3. During the progressive stage of shock, lactic acidosis occurs, resulting in

a.

arterial pooling in the periphery.

b.

constriction of the microcirculation.

c.

increased capillary permeability.

d.

movement of fluid into the capillaries.

ANS: C

Lactic acidosis also causes increased capillary permeability and relaxation of the capillary sphincters. The end result is that the blood supply is progressively retained in the capillary bed and blood pools in the microcirculation.

DIF: Knowledge/Remembering REF: p. 2159 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

4. The nurse has formulated the nursing diagnosis Interrupted Family Processes for the family of a critically ill client in the ICU with shock. The nurse would realize that outcomes for this diagnosis may not have been met when

a.

a member of the family insists on using previous coping mechanisms.

b.

members of the family seem supportive of each other.

c.

the family is willing to participate in decision making.

d.

the nurse has to repeat information several times before it is remembered.

ANS: A

A family member who is rigidly adhering to previous coping methods may not be coping well at all. If the coping methods did not work well when used before, or if they are not working now in the setting of a critical illness in a loved one, the individual needs to learn and use new methods. It is normal for the nurse to have to repeat information several times in this stressful situation. Having the family participate in decision making shows an increased capacity for coping. Certainly when family members seem supportive of each other, it shows they are coping well.

DIF: Evaluation/Evaluating REF: p. 2182 OBJ: Evaluation

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

5. A client is in shock and is receiving naloxone (Narcan). The clients sibling is an EMT and questions why the client is getting medication for an overdose. The most appropriate response by the nurse is

a.

Because of HIPAA laws, I am not allowed to tell you about his/her care.

b.

I dont know but I can have the doctor come and speak with you.

c.

In clients with shock it helps the hypotension and cardiac output.

d.

The client may have gotten too much morphine in the emergency department.

ANS: C

Narcan reduces hypotension and decreases cardiac contractility, which improves hemodynamic status in the setting of shock. Although most familiar as an opioid antagonist for a client who has overdosed, its role in shock may be to mediate the opiate-like substances that are released from the brain. The nurse should follow facility policy in releasing information, but in the ICU, the family of a critically ill client is usually included and given information. If the nurse did not know the reason for the drug, it is most prudent to look it up before giving it.

DIF: Comprehension/Understanding REF: p. 2177 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

6. The nurse closely assesses clients who experience crushing injuries and are in shock because they are more prone than other clients to develop

a.

adult respiratory distress syndrome.

b.

disseminated intravascular clotting.

c.

fat emboli and respiratory distress.

d.

uncompensated metabolic alkalosis.

ANS: B

In shock, the slow-moving acidic blood is hypercoagulable; however, it will not coagulate unless some clot-initiating factor is present. Such factors include bacterial endotoxins and thromboplastin of red blood cells (liberated by hemolysis). Hemolysis accompanies trauma, especially when massive crushing injury occurs. When any of these factors is present, along with the stagnant, acidic blood of shock, widespread intravascular clotting may occur in the vessels.

DIF: Analysis/Analyzing REF: p. 2162 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

7. A client with SIRS is being treated with drotrecogin alfa (Xigris). The client exhibits a decrease in level of consciousness. Which action by the nurse is most important?

a.

Increase the rate of IV infusion.

b.

Notify the physician.

c.

Order a stat ECG.

d.

Take a set of vital signs.

ANS: B

Drotregcogin alfa is used for severe sepsis and SIRS. Its main effect is to reduce the production of thrombin. Bleeding is a significant side effect. An alteration in consciousness must be considered an intracranial hemorrhage until investigated.

DIF: Analysis/Analyzing REF: p. 2177 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

8. The nurse would assess the individual in the most serious stage of shock as a

a.

22-year-old man with a falling BP.

b.

35-year-old woman with a pulse pressure of 40.

c.

50-year-old woman with a MAP of 90.

d.

60-year-old man with a pulse rate of 100.

ANS: A

Some people lose as much as 25% of their total blood volume without having a decrease in BP. This is especially true in young adults; therefore in young adults, falling BP is a very late manifestation of shock. A pulse pressure of 40 is normal ( = pulse pressure of 40). A MAP of 90 would indicate a BP around and is also normal. A pulse of 100 is still considered within the normal range.

DIF: Analysis/Analyzing REF: p. 2166 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

9. The nurse explains that an advantage of the use of hemoglobin-based oxygen carriers (HBOCs), such as PolyHeme and Hemopure, is that these products

a.

decrease the pH of the blood.

b.

do not require type and crossmatch.

c.

function as packed cells at less cost.

d.

increase hemoglobin.

ANS: B

HBOCs expand volume quickly without the delay of type and crossmatch.

DIF: Comprehension/Understanding REF: p. 2175 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Blood and Blood Products

10. The nurse caring for a client in shock who is being mechanically hyperventilated explains that the rationale for this intervention is to

a.

decrease carbon dioxide levels in the blood.

b.

prevent atelectasis and respiratory failure.

c.

rest the client to decrease metabolism.

d.

stimulate endorphin production.

ANS: A

By increasing the rate of pulmonary ventilation (through spontaneous or mechanical hyperventilation), it is possible to compensate for minor degrees of metabolic acidosis. This increased blowing off of carbon dioxide with hyperventilation begins to compensate for acid-base imbalance.

DIF: Comprehension/Understanding REF: pp. 2168-2171

OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

11. The nurse suspects that the client who has entered the emergency department with severe uterine bleeding is in the early stages of shock. The nurses first priority is to

a.

administer oxygen per nasal cannula.

b.

apply super-absorbent perineal pads.

c.

place the client in Trendelenburg position.

d.

start an intravenous line.

ANS: A

The priorities of assessment and care are the ABCs: airway, breathing, and circulation. Given these options, the nurse would first give the client oxygen, then start an IV line. The client would not be placed in Trendelenburg position, as this compresses the diaphragm and interferes with breathing. Perineal pads are not a priority.

DIF: Analysis/Analyzing REF: p. 2178 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

12. When a client is admitted to the emergency department with a gunshot wound to the abdomen and is experiencing severe blood loss, the nurse anticipates the initial use of

a.

dextran.

b.

normal saline.

c.

packed red blood cells.

d.

whole blood.

ANS: B

When shock resulting from hemorrhage is treated, a crystalloid is usually given as an initial emergency treatment to sustain BP. Fluid replacement must include both blood and the fluid lost from the interstitial space. Since blood loss is the problem, blood products will be administered, starting with un-crossmatched universal donor blood, and then when available, crossmatched blood.

DIF: Application/Applying REF: p. 2174 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Parenteral/Intravenous Therapies

13. A client is receiving fluid replacement for treatment of shock and the nurse assesses a central venous pressure (CVP) of 15 cm water. The nurse anticipates which of the following interventions?

a.

Administration of vasoconstrictors

b.

Administration of vasodilators

c.

Decreasing fluid infusion

d.

Increasing fluid infusion

ANS: C

Infusion of blood or other fluids usually continues only as long as the CVP is low; that is, below 4 cm H2O or 2 mm Hg. When the CVP is higher than normal (e.g., greater than 15 cm H2O or 11 mm Hg), benefit cannot be expected from the continued infusion of fluids or blood beyond maintenance amounts.

DIF: Analysis/Analyzing REF: p. 2176 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Parenteral/Intravenous Therapies

14. The nurse is caring for an elderly client who is receiving vasodilators as part of the treatment of shock. The alteration in care the nurse should plan for this client is to

a.

ensure a patent Foley catheter.

b.

keep the head of the bed flat.

c.

provide oxygen by nasal cannula.

d.

run IV fluids at a lower rate.

ANS: B

Vasodilators may be useful in shock when vasoconstriction is severe and persists even though fluids have been infused in what should be adequate amounts for fluid replacement. When the vascular system is full, vasodilators should open arterioles in the lungs and elsewhere. Hypotension may occur and clients should be kept relatively flat in bed. Older clients may have sclerotic blood vessels and may not tolerate any amount of hypotension. If this is the case, a cardiotonic drug may be added to the regimen.

DIF: Analysis/Analyzing REF: p. 2173 OBJ: Intervention

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

15. During treatment for shock, the client receives fluid volume replacement. The nurse determines that renal perfusion is being maintained if the urine output is at least

a.

0.25 ml/kg/hour.

b.

0.5 ml/kg/hour.

c.

1.0 ml/kg/hour.

d.

1.5 ml/kg/hour.

ANS: B

If urine output is absent or less than 0.5 ml/kg/hour, treatment is not successful.

DIF: Application/Applying REF: p. 2167 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

16. Nursing care for a client in hypovolemic shock caused by trauma should include

a.

giving narcotics for pain relief.

b.

maintaining a cool environment.

c.

placing the client in Trendelenburg position.

d.

providing nasogastric suctioning.

ANS: D

An early physiologic response to shock is a decrease in splanchnic circulation. This reduces blood supply to the stomach and bowel, causing inadequate gastrointestinal tissue perfusion and delayed gastric emptying; thus vomiting with aspiration of gastric contents into the lungs may occur. For this reason and for diagnostic purposes, nasogastric suction is often used during treatment of shock.

DIF: Application/Applying REF: p. 2176 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

17. A client in hypovolemic shock has a low pulmonary capillary wedge pressure. This should indicate to the nurse that

a.

fluid replacement is needed.

b.

pulmonary edema may be developing.

c.

resuscitative measures are adequate.

d.

the clients left ventricle is failing.

ANS: A

The pulmonary capillary wedge pressure corresponds to the left ventricular end-diastolic pressure. A low value in a client with hypovolemic shock may indicate that more volume replacement is needed.

DIF: Analysis/Analyzing REF: p. 2176 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Illness Management

18. A client in the ICU has shock and is getting blood glucose levels drawn and treatment with subcutaneous insulin. The clients spouse is upset seeing this and says Now s/hes a diabetic, too? The best response by the nurse is

a.

Blood sugar goes up with physical stress and insulin controls it, and clients seem to do better.

b.

High blood sugar is a common side effect of all these medications we are giving the client.

c.

No, no, s/he is not yet a diabetic. I hope we can prevent it by giving insulin now.

d.

Under great physical stress, blood glucose elevates and people can become diabetic.

ANS: A

Research has shown a significant decrease in mortality and morbidity in ICU clients when insulin is given to maintain tight glycemic control.

DIF: Comprehension/Understanding REF: p. 2177 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

19. The nurse assessing acutely ill clients who are at risk for multiple organ dysfunction syndrome (MODS) would assess for the usual precipitating manifestation of

a.

bradycardia.

b.

cerebral anoxia.

c.

high creatinine level.

d.

hypotension.

ANS: D

There is usually a precipitating event for MODS, including aspiration, ruptured aneurysm, or septic shock, which is associated with resultant hypotension.

DIF: Application/Applying REF: p. 2185 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

20. A client is at risk for MODS. In caring for this client, the nurse should place the highest priority on

a.

assisting with incentive spirometry.

b.

hourly monitoring of urinary output.

c.

maintaining adequate oral intake.

d.

performing range-of-motion exercises.

ANS: A

Because the lungs are often the first organs to fail, they require special attention. Aggressive pulmonary care is needed in all clients who are at risk for MODS.

DIF: Analysis/Analyzing REF: p. 2186 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

21. The nurse caring for a client newly diagnosed with MODS explains that the method of providing nutrition is likely to be

a.

enteral nutrition.

b.

intravenous fluids.

c.

oral diet.

d.

parenteral nutrition.

ANS: A

Because malnutrition develops from the hypermetabolism and the gastrointestinal (GI) tract often seeds other areas with bacteria, some clinicians require the client to be fed enterally. They believe that feeding enhances perfusion and decreases the bacterial load and the effects of endotoxins.

DIF: Comprehension/Understanding REF: p. 2186 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

MULTIPLE RESPONSE

1. Primary prevention techniques the nurse can teach a community group in order to prevent shock include (Select all that apply)

a.

diabetes management.

b.

heart-healthy living.

c.

injury prevention.

d.

safe exercise.

ANS: A, B, C, D

Shock can be prevented by some primary prevention techniques. Clients with diabetes who keep their blood glucose levels under control are less likely to experience hypovolemic shock caused by ketoacidosis. Heart-healthy living can prevent myocardial infarctions with subsequent cardiogenic shock. Injury prevention can focus on preventing trauma that can cause hypovolemic shock from hemorrhage or neurogenic shock from a spinal cord injury. And safe exercising can include being extra cautious in hot weather and drinking plenty of fluids to avoid dehydration that can progress to hypovolemic shock.

DIF: Comprehension/Understanding REF: pp. 2155, 2156, 2157

OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

2. A client is critically ill and in shock. The large, extended family has gathered in the waiting room. Important interventions the nurse can use when working with this family include (Select all that apply)

a.

allow the family to ask questions and express concerns.

b.

avoid explaining a lot of equipment so as not to worry the family.

c.

encourage the family to participate in decision making.

d.

let the family visit the client as much as possible.

e.

provide frequent explanations of what is happening with the client.

ANS: A, C, D, E

Psychosocial care of the client and family is vital to professional nursing, especially when the client is in a life-threatening situation. It is easy to forget this side of nursing, but interventions to support the client and family are critical. All options except b are supportive. Ignorance or misunderstanding the purpose of equipment does nothing to allay anxiety, and in fact can increase it.

DIF: Application/Applying REF: p. 2182 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Stress Management

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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