Which statements about shock are true?
Shock is a whole-body response to tissues not receiving enough oxygen
Shock is widespread abnormal cellular metabolism
Shock occurs only in the acute care setting
Shock may occur in older adults in response to urinary tract infections
Shock is mostly classified as a disease
Shock affects all body organs
Which hormones are released in response to decreased mean arterial pressure (MAP)?
Insulin
Renin
Antidiuretic hormone (ADH)
Epinephrine
Aldosterone
Serotonin
The patient has decreased oxygenation and impaired tissue perfusion. Which clinical manifestations are evidence of onset of the nonprogressive or compensatory states of shock?
Decreased urine output
Low-grade fever
Narrowing pulse pressure
Decreased heart rate
Increased heart rate
Increased sodium reabsorption
Which patients are at risk for shock related to fluid shifts?
a. Hypoglycemic patient
b. Severely malnourished patient
c. Patient with ascites
d. Patient with kidney disease
e. Patient with minor burns
f. Patient with large wound
A young woman comes to the emergency department (ED) with lightheadedness and “a feeling of impending doom.” Pulse is 110 BPM; RR 30; BP 140/90. Which factors does the nurse ask about that could contribute to shock?
a. Recent accident or trauma
b. Prolonged diarrhea or vomiting
c. History of depression or anxiety
d. Possibility of pregnancy
e. Use of OTC medications
f. Recent hospitalization
Which are specific causes or risk factors for cardiogenic shock?
a. Anesthesia
b. Myocardial infarction
c. Cardiac tamponade
d. Ventricular dysrhythmias
e. Constrictive pericarditis
f. Cardiomyopathy
The nursing student takes the morning blood pressure of a postoperative patient, and the reading is 90/50. What does the student do next?
a. Report the reading to the primary nurse as a possible sign of hypovolemia
b. Assess the patient for subjective feelings of dizziness or SOB
c. Check the patient’s chart for trends in morning vital sign readings
d. Notify the instructor to verify the significance of the finding
e. Call a “code blue”
f. Place the patient in reverse Trendelenburg position
For which indications would the nurse be prepared to administer a colloid product?
a. Hemorrhagic shock
b. Dehydration
c. Peripheral tissue hypoxia
d. Fluid replacement
e. Restore osmotic pressure
f. Increase hematocrit and hemoglobin levels
Which question can help guide the nurse when evaluating the mental status of a patient at risk for shock?
a. Is it necessary to repeat questions to obtain a response?
b. Can the patient answer “yes” or “no” questions?
c. Does the response answer the question asked?
d. Does the patient have difficulty making word choices?
e. Is the patient irritated or upset by the questions?
f. How long is the patient’s attention span?
A patient is brought to the emergency department (ED) with a gunshot wound. What are the early signs of hypovolemic shock the nurse should monitor?
a. Elevated serum potassium level
b. Increase in heart rate
c. Decrease in oxygen saturation
d. Marked decrease in blood pressure
e. Increase in respiratory rate
a. Decreased MAP of 10-15 mm Hg
The nurse identifies s/s of internal hemorrhage in a postop patient. What is included in the care of this patient for hypovolemic shock?
a. Elevate the feet with the head flat or elevated 30 degrees
b. Monitor VSs every 5 minutes until they are stable
c. Administer clotting factors or plasma
d. Provide oxygen therapy
e. Ensure IV access
f. Leave the patient and notify the Rapid Response Team
A patient with hypovolemic shock is receiving an infusion of dopamine. Which nursing interventions are essential when a patient is receiving this drug?
a. Take the BP at least every 15 minutes
b. Monitor urine output every hour
c. Cover the infusion bag to protect it from light
d. Assess the patient for chest pain
e. Check the infusion site every 30 minutes for extravasation
f. Ask a patient receiving this drug about headaches
A patient with hypovolemia is restless and anxious. The skin is cool and pale, pulse is thread at a rate of 135bpm, BP 92/50, and RR 32. What actions must the nurse take?
a. Obtain a stat order for an IV normal saline bolus
b. Check vital signs at least every 15 minutes
c. Notify the Rapid Response Team
d. Place the patient in a semi-Fowler’s position
f. Administer supplemental oxygen
The nurse finds a patient on the bathroom floor. There is a large amount of blood on the floor and on the patient’s hospital gown. Which actions must the nurse take?
a. Elevate the patient’s legs
b. Establish large-bore IV access
c. Look for the sourc3e of bleeding
d. Ensure a paten airway
e. Apply direct pressure to the bleeding site if possible
f. Check vital signs at least every 30 minutes
A patient is being discharged from the same-day surgery unit to home. Which early indicators of shock will the nurse teach the patient and family member to watch for and to seek medical attention immediately if they occur?
a. Decreased thirst
b. Decreased urine output
c. Increased blood pressure
d. Lightheadedness
e. Sense of apprehension
f. Cyanosis
The nurse is preparing a teaching session or a patient at risk for septic shock. Which topics does the nurse include in this teaching?
a. Wash hands frequently using antimicrobial soap
b. Avoid aspirin and aspirin-containing products
c. Avoid large crowds or gatherings where people might be ill
d. Do not share eating utensils
e. Wash toothbrushes in a dishwasher
f. Take temperature once a week
The home health nurse is visiting a fail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. What does the nurse assess this patient for?
a. Signs of skin breakdown and presence of redness or swelling
b. Cough or any other symptoms of a cold or the flu
c. Appearance and odor of urine, and pain or burning during urination
d. Patient’s and family’s understanding of isolation precautions
e. Availability and type of facilities for handwashing
f. General cleanliness of the patient’s home
Which patients are at risk for distributive septic shock?
a. Older adult with UTI
b. Patient with ruptured aortic aneurysm
c. Patient with pneumonia
d. Patient receiving heparin therapy
e. Older adult with sacral pressure ulcers
f. Older adult scheduled for outpatient colonoscopy
The patient has been diagnosed with sepsis. Following the sepsis resuscitation bundle, which interventions should the nurse expect within the first 3 hours?
a. Obtain serum lactate level
b. Begin administering vasopressor drugs
c. Draw blood cultures
d. Administer broad-spectrum antibiotics
e. Assist with insertion of a central venous pressure line
f. Immediately transfer to the ICU
