Chapter 61
Describe the body’s response to shock.
1. When caring for a group of clients, the nurse observes which of the following clients for
signs and symptoms of hemorrhagic shock?
• Client 6 hours postmastectomy
• Client who had a DVT after a surgical procedure 2 years earlier
• Client sustaining a transmural myocardial infarction 2 days ago
• Client with coronary atherosclerosis who takes 81 mg of aspirin daily
Answer: Client 6 hours postmastectomy
Rationale:
Postoperative clients are at risk for hemorrhage; mastectomy clients typically have drains
whose output should be carefully documented. A past history of DVT is not pertinent to
hemorrhage, as DVT is caused by a clot. A large myocardial infarction may lead to
cardiogenic shock, not hemorrhage. The antiplatelet properties of aspirin may predispose to
bleeding; however, there is no indication of trauma or bleeding.
2. The nurse is caring for a client with papillary muscle rupture. When assessing the client,
the nurse is alert to the development of symptoms related to _________ shock?
1. Cardiogenic
2. Anaphylactic
3. Neurogenic
4. Septic
Answer: Cardiogenic
Rationale:
The papillary muscle holds the valves in place and may be damaged during MI, the most
common reason for cardiogenic shock. Anaphylactic shock develops from hypersensitivity
reactions. Neurogenic shock results from spinal cord injury or vasodilatation below the level
of spinal anesthesia, and septic shock results from overwhelming infection.
Client need Category: Physiological Integrity
3. The nurse is caring for a client with endocarditis who is receiving penicillin. The nurse
should be particularly attentive to recognize early symptoms of which of the following types
of shock?
1. Anaphylactic
2. Cardiogenic
3. Hypovolemic
4. Septic
Answer: Anaphylactic
Rationale:
A hypersensitivity to medications, particularly penicillins, may occur at any time during
initial or subsequent treatments with the drug. Cardiogenic shock results from loss of
pumping ability due to damage to the left ventricle such as after MI. Hypovolemic shock
results from decreased vascular fluid volume. Septic shock results from overwhelming
infections and the SIRS.
4. When caring for a client in shock, the nurse recognizes that consequences of decreased
blood flow to the kidney will result in:
1. Azotemia.
2. Elevated ammonia level.
3. Hypokalemia.
4. Hyperglycemia.
Answer: Azotemia.
Rationale:
Impaired tissue perfusion to the kidney will result in decreased perfusion and build up of
nitrogenous wastes, or azotemia. Increased ammonia levels result from decreased perfusion
to the liver. Hypokalemia does not typically appear in a shock state with metabolic acidosis;
hyperkalemia may be present. Hyperglycemia is related to stress response and catecholamine
release, not poor renal tissue perfusion.
5. The nurse is caring for a client who has developed septic shock related to cancer
chemotherapy. The nurse recognizes changes in mental status most likely result from:
1. Decreased tissue oxygenation.
2. Metastasis of underlying cancer.
3. Anxiety about and fear of death.
4. A result of chemotherapy.
Answer: Decreased tissue oxygenation.
Rationale:
Clients at risk for septic shock include those who are immunosuppressed, have invasive
technology, or infections. Metastasis to the brain may cause confusion, but not sepsis.
Anxiety and fear may lead to confusion, but not sepsis. “Chemo brain” has been documented
as a cause of confusion, but not sepsis.
6. The nurse is evaluating acid−base status in a client with septic shock. Which of the
following alterations is anticipated?
1. HCO3 of 10 mEq/L
2. pH of 7.46
3. pCO2 of 35 mm HG
4. pO2 of 77 mm HG
Answer: HCO3 of 10 mEq/L
Rationale:
Septic shock results in lactic acidosis secondary to tissue hypoxia, which is manifested in a
decreased bicarbonate level. A pH of 7.46 is normal. A pCO2 of 35 mm is normal. A pO2 of
>75−80 is normal.
7. The family of a client in shock asks why the client’s hands are cold. The nurse’s best
response is which of the following?
1. “Blood vessels constrict in shock, which takes the blood away from hands and feet.”
2. “We keep the intensive care unit cool to reduce clients’ metabolic rate.”
3. “Your family member has developed a fever and chills.”
4. “This happens frequently to clients in shock states.”
Answer: “Blood vessels constrict in shock, which takes the blood away from hands and feet.”
Rationale:
Vasoconstriction results from catecholamine release, which is a compensatory mechanism in
shock. Cooling measures are used in shock for fever; the ICU is not purposefully chilled.
There is no indication that the client has developed fever and chills.
Stating that cold hands happen frequently does not answer the family member’s question.
Physiological Integrity
8. The nurse anticipates that catecholamine release in shock may result in which of the
following?
1. Hyperglycemia
2. Bradycardia
3. Pinpoint pupils
4. Thirst
Answer: Hyperglycemia
Rationale:
Catecholamine release causes breakdown of glycogen to glucose, leading to hyperglycemia.
Bradycardia is not a consequence of catecholamine release; tachycardia is. Pinpoint pupils
are not a result of catecholamine release; mydriasis is. Thirst is a symptom of hypovolemic
shock; it is not specific to catecholamine release.
Physiological Integrity
9. When assessing a client in shock who takes a beta adrenergic blocker, the nurse recognizes
that which of the following responses to shock may be altered?
1. Tachycardia
2. Hypotension
3. Bowel sound
4. Cyanosis
Answer: Tachycardia
Rationale:
Beta adrenergic blockers inhibit the sympathetic nervous system, causing bradycardia.
Hypotension will still occur with beta-blocker therapy, as the therapeutic effect of a beta
blocker is to reduce blood pressure. Beta-blockers may cause constipation; decreased bowel
sounds are expected in shock states. Cyanosis will still occur in a shock state, as betablockers do not interfere with symptoms of poor oxygenation.
10. The nurse is evaluating the clients in an intensive care unit for risk for sepsis and septic
shock. Clients at risk for sepsis include the client:
Select all that apply.
1. From a nursing home with a stage 4 pressure ulcer.
2. With rheumatoid arthritis taking methotrexate.
3. With aplastic anemia.
4. With blunt trauma spinal cord injury.
5. With ruptured viscus vomiting bright red blood.
Answer: 1. From a nursing home with a stage 4 pressure ulcer.
2. With rheumatoid arthritis taking methotrexate.
3. With aplastic anemia.
Rationale:
From a nursing home with stage 4 pressure ulcer. Breaches in skin integrity such as pressure
ulcers are risks for sepsis and septic shock. With rheumatoid arthritis taking methotrexate.
Clients such as those taking methotrexate for chemotherapy or immune modulation are at risk
for sepsis and septic shock. With aplastic anemia. Aplastic anemia results in suppression of
all cellular elements of the bone marrow, including WBCs, which puts the client at risk for
infection and sepsis. With blunt trauma spinal cord injury. Blunt spinal cord injury may lead
to spinal or neurogenic shock. With ruptured viscus vomiting bright red blood. Fluid-volume
deficit secondary to hematemesis may lead to hypovolemic shock.
11. When caring for a group of critically ill clients, the nurse recognizes that which of the
following patients has risk for increased mortality from sepsis?
1. A 20-year-old student with diabetes
2. A 32-year-old accountant with a head cold
3. A 60-year-old homemaker
4. A 40-year-old with hyperparathyroidism
Answer: A 20-year-old student with diabetes
Diabetes increases the risk of death from sepsis, as hyperglycemia promotes inflammation
and increases the risk of ODS and death. Others at risk are those of advanced age, patients
with cancers, and the immunosuppressed client. A head cold, a homemaker, and
hyperparathyroidism do not have the same risks for death as the clients previously described.
12. The nurse is caring for a group of clients in a critical care unit. Which of the following
clients does the nurse identify as at risk for hypovolemic shock?
Select all that apply.
1. Client with ruptured abdominal aortic aneurysm
2. Client with cirrhosis, ascites, and anasarca
3. Client in a multivehicle collision
4. Client sustaining a myocardial infarction
5. Client with systemic lupus erythematosus
Answer: 1. Client with ruptured abdominal aortic aneurysm
2. Client with cirrhosis, ascites, and anasarca
3. Client in a multivehicle collision
Rationale:
Client with ruptured abdominal aortic aneurysm. Clients at risk for hypovolemic shock
include those with hemorrhage and GI bleeding. Client with cirrhosis, ascites, and anasarca.
Clients at risk for hypovolemic shock include those with hemorrhage, GI bleeding, third
spacing, and unreplaced fluid loss. Client in a multivehicle collision. Clients at risk for
hypovolemic shock include those with abdominal injury or trauma. Client sustaining a
myocardial infarction. A myocardial infarction may lead to cardiogenic, not hypovolemic,
shock. Client with systemic lupus erythematosus. A client treated for lupus typically takes
immunosuppressing drugs such as corticosteroids, placing the client at risk for septic shock.
13. The nurse is caring for an 80-year-old client with septic shock admitted from a nursing
home earlier today. Which of the following should the nurse consider the most likely source
of the sepsis?
1. An indwelling Foley catheter inserted by nursing home personnel
2. An intravenous catheter inserted in the field
3. A red, flat rash in the perineal area
4. Exposure to the client’s daughter who is receiving chemotherapy
Answer: An indwelling Foley catheter inserted by nursing home personnel
Rationale:
A major cause of sepsis is indwelling urinary catheters. An intravenous catheter inserted in
the field would not cause sepsis if just inserted. A perineal rash without open skin will not
contribute to sepsis. The client’s daughter who receives chemotherapy is at risk for infection
and sepsis, not the client.
14. When caring for a client with suspected cardiogenic shock, which of the following would
be most helpful in confirming the underlying cause?
1. Monitoring cardiac enzymes
2. Monitoring mean arterial pressure using an intra-arterial line
3. Measuring the central venous pressure
4. Monitoring pulmonary artery pressure
Answer: Monitoring cardiac enzymes
Rationale:
Measuring cardiac enzymes will determine the presence of myocardial infarction, the major
cause of cardiogenic shock. Arterial pressure monitoring is useful in all shock states, but is
not specific to cardiogenic shock. Central venous pressure assesses fluid volume, and is not
specific to cardiogenic shock. Pulmonary artery pressures assess for pulmonary artery
hypertension and fluid volume, and are not specific to cardiogenic shock.
15. When caring for a patient who was stabbed in the abdomen, the nurse recognizes that 2
liters of fluid given over the last hour have been ineffective when the patient displays which
of the following?
1. Heart rate 142 and regular
2. Blood pressure 94/50
3. Urine output of 45 ml for this hour
4. Patient complains of abdominal pain
Answer: Heart rate 142 and regular
Rationale:
Evidence of successful fluid resuscitation includes heart rate 90 mmHG systolic, urine output of at least 30
ml/hour or 0.4 to 1.0 ml/kg/hour. Presence of abdominal pain is not an outcome criterion for
shock.
16. When admitting a client with septic shock, the nurse focuses on which of the following
potential causes in the patient’s history?
1. Client has received a liver transplant 3 months prior
2. Client underwent cholecystectomy last year
3. Client has a history of kidney stones
4. Client states he had a heart attack last month
Rationale:
The client who has received an organ transplant must take immunosuppressant drugs for the
life of the transplant, which places the individual at risk for sepsis. A client who has
recovered from cholecystectomy, kidney stones, or MI is not at risk for sepsis.
17. In order to protect the airway in a client with a Glasgow Coma Scale score of 3, the nurse
collaborates with the health care team to assist with which of the following?
1. Endotracheal intubation
2. Assessment of bowel sounds
3. Monitoring oxygen saturation
4. Questioning the client regarding difficulty breathing
Answer: Endotracheal intubation
Rationale:
A Glasgow Coma Scale score of 3 indicates a very decreased level of consciousness; the
priority is to protect the airway. Bowel sounds may be absent in shock; the ABCs are
addressed first. Questioning regarding difficulty breathing is not done because the client is
not verbal with a Glasgow Coma Scale score of 3.
18. When caring for the client in septic shock, the nurse recognizes fluid replacement is
inadequate when which of the following is noted?
1. Urine output 10 milliliters for the last hour
2. Pulse rate of 100 beats per minute
3. MAP 75
4. Central venous pressure is 5 mmHG
Answer: Urine output 10 milliliters for the last hour
Rationale:
Adequate blood flow to the kidneys is measured by urine output of 0.5 ml/kg/hour. A heart
rate of 100 is considered acceptable in shock. MAP should be kept > 65 mmHG. Normal
CVP is 4 to 12.
19. A client with hemorrhagic shock is receiving norepinephrine (Levophed) by continuous
infusion. Which of the following outcomes is anticipated?
1. Blood pressure of 100/54
2. Reduction in bleeding
3. Reduced apical heart rate
4. Decline in cardiac enzymes
Answer: Blood pressure of 100/54
Rationale:
Norpinephrine (Levophed) is a catecholamine used in shock to raise blood pressure.
Reduction in bleeding is not the intended effect; bleeding may actually increase as blood
pressure is restored. The apical pulse would increase related to the catecholamine effects;
therefore reduced heart rate is not the intended outcome. A decline in cardiac enzymes is not
anticipated, as norepinephrine increases afterload and cardiac workload; this is not the
intended effect.
20. The nurse is caring for a client with septic shock. Which of the following findings is
present in septic shock?
1. Patient with infection, blood pressure 84/52 after 4 liters of saline
2. Patient with burns over 40% of the body and febrile
3. A patient with WBC count of 22,000 and fever
4. Patient with respiratory failure and community-acquired pneumonia
Answer: Patient with infection, blood pressure 84/52 after 4 liters of saline
Rationale:
By definition, septic shock exists when sepsis is refractory to fluid resuscitation. A burn
injury with fever does not meet the criteria for severe sepsis. A high WBC count and fever
may be present in an uncomplicated infection. Respiratory failure secondary to pneumonia
does not indicate presence of severe sepsis with shock.
21. When caring for a client with sepsis, the nurse recognizes that which of the following
indicates a progression to severe sepsis?
Select all that apply.
1. Client requires intubation and mechanical ventilation for respiratory failure
2. Blood pressure of 80/42 after 4 liters of fluid have been given
3. Hematuria, epistaxis, and oozing from central venous catheter site
4. WBC count of 4000 cells/cubic millimeter
5. Urine output of 40 to 60 milliliters per hour
Answer: 1. Client requires intubation and mechanical ventilation for respiratory failure
2. Blood pressure of 80/42 after 4 liters of fluid have been given
3. Hematuria, epistaxis, and oozing from central venous catheter site
Rationale:
Client requires intubation and mechanical ventilation for respiratory failure. Severe sepsis is
defined as the presence SIRS with hypotension/shock, a confirmed infection, and single or
multiple organ failure. Inability to manage maintenance respiratory functions is consistent
with a worsening condition. Blood pressure of 80/42 after 4 liters of fluid have been given.
Continuing hypotension after the administration of treatment indicates a continuation of
responses. Hematuria, epistaxis, and oozing from central venous catheter site. Coagulopathy
may be a manifestation of worsening sepsis. WBC count of 4000 cells/cubic millimeter. A
WBC count of 4000 is normal. Urine output of 40 to 60 milliliters per hour. Urine output of
40 to 60 ml/hour (or 0.5 ml/kg/hour) is normal.
21. The nurse is reviewing the diagnostic tests for a client with an infection. Which of the
following indicates the presence of sepsis?
1. Decreased activated protein C
2. Potassium 2.9 mEq/L
3. WBCs 5000 cells/cubic mm
4. Hemoglobin 8.5 gm/dL/Hematocrit 25.2%
Answer: Decreased activated protein C
Rationale:
A decreased activated protein C level is associated with sepsis, coagulopathy, MODS, and
increased mortality. Potassium levels are not specific to the diagnosis of sepsis. WBC count
of 5000 is normal. A low H & H indicates hemorrhage or destruction of cells.
22. The nurse plans to administer fluid to a client with SIRS and hypotension. Which of the
following orders should the nurse anticipate to prevent progression of shock?
1. Administer 1000 ml of lactated ringers over the next 2 hours.
2. Infuse 20 ml of D5½ normal saline solution per hour.
3. Give 3% saline at a rate of 20 ml/hour.
4. Administer D5W at a rate of 100 ml/hour.
Answer: Administer 1000 ml of lactated ringers over the next 2 hours.
Rationale:
Isotonic solutions, such as normal saline or lactated ringers, should be administered at a rate
of 20 ml/kg/hr and increased to maintain urine output of 0.5 ml/kg/hr. D5½ normal saline is a
slightly hypertonic fluid; the rate of infusion is too low for patients in shock. Three percent
saline is hypertonic. D5W is a hypotonic solution.
23. The critical care nurse is delivering a peer lecture on guidelines for the management of
SIRS and severe sepsis. Current evidence suggests which of the following will improve
outcome in septic shock?
1. Maintain blood glucose between 110 and 134 mg/dL
2. Antibiotic therapy initiated prior to end of shift
3. Mechanical ventilation with tidal volume of 10 ml/kg
4. Bicarbonate used for pH of 7.30
Answer: Maintain blood glucose between 110 and 134 mg/dL
Rationale:
Current evidence indicates that maintaining blood glucose 101 degrees.
2. Place the client on a high-fat diet to increase energy.
3. Provide skin care and positioning to prevent breakdown.
4. Use meticulous hand hygiene and aseptic technique for procedures.
Answer: Administer antipyretics for fever >101 degrees.
Rationale:
Reducing fever will decrease metabolic rate and oxygen demand. A high-fat diet is not
indicated in shock; however, attention to nutrition and adequate calories is necessary. Skin
care and positioning are essential to prevent breakdown and further entry of bacteria into the
body, but will not reduce oxygen demands. Asepsis and hand washing are essential to prevent
further infection, but will not reduce oxygen demand.
26. The nurse is caring for a client with septic shock and MODS. The client’s family member
tearfully tells the nurse, “The doctor said my mother’s organs are shutting down. How did
that happen?” Which of the following is the best response?
1. “Deprivation of oxygen during shock causes organs to fail to function properly.”
2. “The infection attacks and destroys each organ, causing them to fail.”
3. “Fever damages the brain, which controls all organs.”
4. “The stress of illness has overwhelmed your loved one.”
Answer: “Deprivation of oxygen during shock causes organs to fail to function properly.”
Rationale:
The cascade of events in shock states results in inadequate tissue perfusion and hypoxia
leading to organ failure. Infection does not strike each organ; rather, an inflammatory process
begins a cascade of events impairing tissue perfusion that causes organs to fail. Fever may
cause brain damage if exceedingly high and increase metabolic demand, increasing oxygen
demand, but it is not the primary reason for MODS. The stress response is activated as a
compensatory mechanism; however, it is not the primary reason for MODS.
27. When planning care for a client with MODS secondary to septic shock, the nurse suggests
which of the following to the provider, as evidence shows a reduction in mortality?
1. Recombinant activated protein C (xigris)
2. Heparin
3. Packed red blood cell transfusion
4. Dobutamine (Dobutrex)
Answer: Recombinant activated protein C (xigris)
Rationale:
Recombinant activated protein C (xigris) is indicated for clients with a high risk of death,
such as organ failure. Heparin is not typically used in the treatment of septic shock. Packed
red blood cell transfusions are used to increase the oxygen-carrying capacity of the blood,
such as after hemorrhage. Blood transfusions do not improve survival in septic shock.
Dobutamine is added in septic shock to improve cardiac output, but has not been shown to
improve survival.
28. Which of the following is the priority for a client with MODS and adult respiratory
distress syndrome (ARDS)?
1. Maintain oxygen saturation 88% to 92%.
2. Provide mechanical ventilation with tidal volume of 10 ml/kg.
3. Administer sodium bicarbonate for pH of 7.31.
4. Provide frequent mouth care to prevent ventilator-associated pneumonia.
Answer: Maintain oxygen saturation 88% to 92%.
Rationale:
The goal of therapy in shock is to maintain tissue perfusion with oxygen saturation 88% to
92% or more. Mechanical ventilation is provided with low tidal volumes of 4 to 6 ml/kg.
Bicarbonate is given for pH<7.1. Frequent mouth care is an intervention, but not a higher
priority than airway management.
29. The nurse is caring for a client with MODS secondary to septic shock whose urine output
was 10 ml for the last 2 hours. Temperature is 97 degrees, pulse is 124 and thready, and BP is
88/48. Which of the following orders is the priority at this time?
1. Administer isotonic fluids at 20 ml/kg/hr.
2. Draw blood for BUN and creatinine.
3. Place the client in a kinetic bed.
4. Place the client on a warming blanket.
Answer: Administer isotonic fluids at 20 ml/kg/hr.
Rationale:
The client has entered the cold or hypodynamic phase of shock characterized by vasodilation
and profound hypotension. Fluids are indicated to improve blood pressure and blood flow
through the kidney. BUN and creatinine may be evaluated to determine the consequence of
renal blood flow, but this is done after the ABCs have been addressed. A kinetic bed will
decrease pressure on the skin and prevent breakdown secondary to decreased tissue
perfusion, but is performed after the ABCs are addressed. A low body temperature in the cold
or hypodynamic phase is expected; warming may cause vasodilation and lowered blood
pressure. Treating the underlying cause of hypoperfusion to the kidneys is indicated.
30. Which of the following should take priority in a patient with MODS secondary to severe
sepsis?
1. pO2 of 54 mmHg
2. WBC count of 28,000 cell/cubic mm
3. Serum lactate level is 2 mmol/L
4. Blood glucose of 245 mg/dL
Answer: pO2of 54 mmHg
Rationale:
The nurse follows the ABCs for priority; a pO2 of 54 mmHg reflects hypoxemia, the priority.
A WBC count of 28,000 cells indicates infection; antibiotics are begun within the first hour of
identifying severe sepsis, but not before airway and breathing are restored. A serum lactate
level of 2 mmol/L is normal. Blood glucose level should be controlled, but not before the
airway and breathing are corrected.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
