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Chapter 39: Care of Patients with Shock

Test Bank
MULTIPLE CHOICE
1. The intensive care nurse is educating the spouse of a client who is being treated for shock. The

spouse states, “The doctor said she has shock. What is that?” What is the nurse’s best
response?
a. “Shock occurs when oxygen to the body’s tissues and organs is impaired.”
b. “Shock is a serious condition, but it is not a life-threatening emergency.”
c. “Shock progresses slowly and can be stopped by the body’s normal compensation.”
d. “Shock is a condition that affects only specific body organs like the kidneys.”
ANS: A

Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of
shock and lead to a life-threatening emergency. Shock represents the “whole-body response,”
affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain
homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal
of the cause of shock, resulting in death.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 809
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is caring for multiple clients in the emergency department. The client with which

condition is at highest risk for distributive shock?
Severe head injury from a motor vehicle accident
Diabetes insipidus from polycystic kidney disease
Ischemic cardiomyopathy from severe coronary artery disease
Vomiting of blood from a gastrointestinal ulcer

a.
b.
c.
d.

ANS: A

Distributive shock is the type of shock that occurs when blood volume is not lost from the
body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen.
Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord
injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 812
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates

that the client is at risk for acidosis?
Decreased serum creatinine
Increased serum lactic acid
Increased urine specific gravity
Decreased partial pressure of arterial carbon dioxide

a.
b.
c.
d.

ANS: B

resulting in an increase in hydrogen ion production and acidosis. 812 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis) 4. ANS: B Ringer’s lactate is an isotonic solution that acts as a volume expander. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Parenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation) 6. and kidney function progress. respiration. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. changes in skin. Increase in cardiac output . Which manifestation is a desired response to this medication? a. DIF: Cognitive Level: Comprehension/Understanding REF: p. the lactate acts as a buffer in the presence of acidosis.The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation. “Is your skin usually cool and pale?” ANS: C The first manifestations of hypovolemic shock result from compensatory mechanisms.45% normal saline a. “Are you more thirsty than normal?” b. Decrease in blood pressure b. The other solutions do not contain any substance that would buffer or correct the client’s acidosis. Also. thus some cells are metabolizing anaerobically. b. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. “When was the last time you urinated?” c. As shock progresses. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 5. Which fluid does the nurse prepare to administer? Normal saline Ringer’s lactate 5% dextrose in water 5% dextrose in 0. “What is your normal heart rate?” d. Urine specific gravity is not associated with acidosis. Such metabolism increases the production of lactic acid. Increase in heart rate c. d. The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Signs of shock are first evident as changes in cardiovascular function. The other questions would not identify early stages of shock. c.

A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Assess the client’s blood pressure every 15 minutes. Tachycardia is not a desired response but often occurs as a side effect. Aminoglycosides and heparin are given to clients with septic shock. a. a. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation) 9. what is the priority intervention for this client? Administer an aminoglycoside. Which nursing intervention is a priority when administering this medication? Ask if the client has chest pain every 30 minutes. b. and extremities. Administer crystalloid fluids. The nurse is caring for a client who has hypovolemic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Parenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Evaluation) 8. . c. ANS: B The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes.d. Decrease in mean arterial pressure ANS: C Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure. After administering oxygen. Monitor the client’s urinary output every hour. Higher doses can cause systemic vasodilation and can increase shock. The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. but these assessments do not directly relate to the nitroprusside infusion. d. c. Protect the medication from light with an opaque bag. Observe the client’s extremities every 4 hours. b. thereby improving tissue perfusion and oxygenation. d. d. The nurse should monitor the client’s pain. The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. urinary output. 818 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation) 7. Initiate a dopamine hydrochloride (Intropin) drip. DIF: Cognitive Level: Comprehension/Understanding REF: p. b. Initiate an intravenous heparin drip. c. ANS: C IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. Assess the client’s respiratory rate. Which important action related to the administration of this drug does the nurse implement? a. Administer the medication with gravity tubing. Monitor for hypertensive crisis.

The nurse is assessing a client who was admitted for treatment of shock. It should be delivered via pump. Obtain central venous pressure (CVP) measurements. The nurse is caring for a client who has had an anaphylactic event. A client who has septic shock is admitted to the hospital. Hypertension is a sign of milrinone (Primacor) overdose. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Parenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation) 10. b. d. The other clinical manifestations do not relate to anaphylaxis or distributive shock. If hypotension occurs. d. b. d. ANS: D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 11. Administer the prescribed IV norepinephrine (Levophed). This results in massive blood vessel dilation and increased capillary leak. which manifests as swelling. b. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock? “Is your blood pressure higher than usual?” “Are you having pain in your throat?” “Have you been vomiting?” “Are you usually this swollen?” a. a. What priority intervention does the nurse implement first? Obtain two sets of blood cultures.ANS: C Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. ANS: D . c. CVP monitoring and vasopressor therapy are started if hypotension persists. Which manifestation indicates that the client’s shock is caused by sepsis? Hypotension Pale clammy skin Anxiety and confusion Oozing of blood at the IV site a. c. Administer the prescribed IV vancomycin (Vancocin). DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 12. fluid resuscitation is used first. c. ANS: A Blood cultures should be obtained before IV antibiotics are started. This medication does not have any effect on respiratory rate.

A client was admitted 2 days ago with early stages of septic shock. The distinguishing feature is lack of ability to clot blood. such as having cancer and being treated with chemotherapeutic agents. The other client situations do not increase the client’s risk for septic shock. Ask the client’s family to come to the hospital because death is near. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis) 14. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 13. Vitamin K c. Today the nurse notes that the client’s systolic blood pressure. can predispose a person to septic shock. and cardiac output are decreasing rapidly. The nurse is assessing clients in the emergency department. d. Corticosteroids .The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. Obtain blood cultures before administering the next dose of antibiotics. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. and certain antibiotics. The family should be updated appropriately. pulse pressure. systolic blood pressure. Which client is at highest risk for developing septic shock? 25-year-old man who has irritable bowel syndrome 37-year-old woman who is 20% above ideal body weight 68-year-old woman who is being treated with chemotherapy 82-year-old man taking beta blockers for hypertension a. c. c. ANS: C Certain conditions or treatments that cause immune suppression. d. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 15. The other manifestations are associated with all types of shock. b. causing the client to bleed from areas of minor trauma and to bleed spontaneously. Initiate the prescribed dobutamine (Dobutrex) intravenous drip. aspirin. Which medication does the nurse expect to be prescribed? a. and pulse pressure. b. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client’s pulse pressure is decreasing rapidly. Heparin sodium b. Insert a Foley catheter to monitor urine output closely. ANS: C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output. Which intervention does the nurse do first? a. The nurse is caring for a client in the hyperdynamic phase of septic shock.

clients begin to form numerous small clots. All of the following treatments have been prescribed. ANS: A Therapy during the second (late) phase of septic shock is aimed at enhancing the blood’s ability to clot. Heparin is administered to limit clotting and prevent consumption of clotting factors. Notify the health care provider. The nurse is planning care for a client with late-phase septic shock. Which prescription does the nurse question? Enoxaparin (Lovenox) 40 mg subcutaneous twice daily Transfusion of 2 units of fresh frozen plasma Regular insulin intravenous drip per protocol Cefazolin (Ancef) 1 g IV every 6 hours a. platelets. b. Hetastarch (Hespan) ANS: A During the hyperdynamic phase of septic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy— Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 16. What priority information does the nurse include in the teaching plan for this client? . The nurse is assessing a client at risk for shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care— Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 18. a. Enoxaparin would increase the client’s risk of bleeding and therefore should not be administered during the last phase of septic shock. Place the client in high Fowler’s position. ANS: B Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. A client recovering from septic shock is preparing for discharge home. The client’s systolic blood pressure is 20 mm Hg lower than baseline. and other blood products will assist the client’s blood to clot.d. plasma. b. Administering clotting factors. c. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock. because of alterations in the clotting cascade. The other medications would not be prescribed during the hyperdynamic phase of septic shock. Administer oxygen. Which intervention does the nurse perform first? Increase the IV fluid rate. The other interventions should be completed after oxygen is administered. d. d. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy— Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) 17. c.

“In a hot and dry environment. you should drink adequate fluids when you exercise. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. The client should refrain from cleaning pet litter boxes. the groin. d.a. ANS: B Hypovolemic shock can be caused by dehydration. d. “We are not at risk because we live in a hot and dry climate. c. The emergency department nurse is triaging clients. The other statements are not accurate. which causes the body to lose water. “Even though you are not at risk. smoking.” c. Insensitive water loss increases in this type of environment. “Clean your toothbrush with laundry bleach daily. Which client does the nurse assess most carefully for hypovolemic shock? 15-year-old adolescent who plays high school basketball 24-year-old computer specialist who has bulimia 48-year-old truck driver who has a 40-pack-year history of smoking 62-year-old business executive who travels frequently a. b. The nurse is providing community education for clients at risk for dehydration.” What is the nurse’s best response? a.” “Bathe every other day with antimicrobial soap. either by running it through the dishwasher or by rinsing it in laundry bleach. “Any type of heat can cause peripheral vasoconstriction. Heat causes vasodilation as well. also contributing to water loss. Basketball. and the rectal area. Clients recovering from septic shock are not at higher risk for bleeding disorders. b. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation) 19.” d. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 20. c.” b.” “Use an electric razor when you shave your face. the body can lose an increased amount of water without your knowledge. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) .” ANS: A The client at risk for septic shock should be instructed to clean his or her toothbrush daily. “You are still at risk but not as high a risk as those who live in hot and humid climates. One client states. Clients should be instructed to bathe daily and wash the armpits.” ANS: C Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment.” “Wash your hands after changing pet litter boxes. and traveling do not put the client at risk for hypovolemic shock.

” b.” ANS: A A decrease in urine output is a sensitive indicator of early shock. Treatment should include administration of low-dose corticosteroids. The nurse teaches the client to seek immediate medical attention if which complication occurs? Dizziness on changing position Increased urine output Warmth and redness at site Low-grade temperature a. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. Alterations in temperature. irregular rhythms. “Assess your radial pulse every day and report an irregular rhythm. Which nursing intervention is most appropriate during this stage of sepsis? a. b. insulin drip with blood glucose checks every 1 to 2 hours. c. and changes in bowel movements are not early signs of shock. b. ANS: A When a local infection becomes systemic. the client may exhibit orthostatic hypotension. . and an increase in ventilator rate and tidal volume. interventions should focus on decreasing hypoxia. “Monitor your bowel movements and report ongoing constipation or diarrhea. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock? a. Decrease ventilator rate and tidal volume.” d. maintaining organ perfusion. and decreasing microemboli. In severe shock. the client develops a high-grade temperature. and increased respiratory rate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 23. d. “Take your temperature daily and report any below-normal body temperatures.” c. Check blood glucose levels every 4 hours. decreased urine output. Warmth and redness are expected with local infection. The nurse is planning discharge education for a client who had an exploratory laparotomy. The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. c. urine output is decreased (compared with fluid intake) or even absent. Monitor intake and urinary output twice each shift. keeping blood glucose levels as normal as possible. A client who has a local infection of the right forearm is being discharged. hourly intake and output monitoring. maintaining acidbase balance. The other signs are not manifestations of complications. minimizing adrenal insufficiency. ANS: D During severe sepsis. Because of tachycardia and low blood pressure. “Monitor how much urine you void and report a decrease in the amount. Administer prescribed low-dose corticosteroids. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 22.MSC: Integrated Process: Nursing Process (Assessment) 21. d.

e. Early b. b. D Heart and respiratory rates increased from the client’s baseline level and a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.” “Take your temperature once a day. Intermediate d. These findings do not correlate with other stages of shock.) “Wear a facemask at all times. 813 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2. The nurse is assessing a client who is in early stages of hypovolemic shock. Compensatory c.” “Drink only bottled water. The nurse is assessing a client who has septic shock. d. The following assessment data were collected: Baseline Data Today’s Data Heart rate 75 beats/min 98 beats/min Blood pressure 125/65 mm Hg 128/75 mm Hg Respiratory rate 12 breaths/min 18 breaths/min Urinary output 40 mL/hr 40 mL/hr The nurse correlates these findings with which stage of shock? a. b. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) MULTIPLE RESPONSE 1.” “Avoid any contact with pets. The nurse is providing health education to a client on immunosuppressant therapy.” a. ANS: A. . DIF: Cognitive Level: Knowledge/Remembering REF: p.DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Intervention) 24. d.) Elevated heart rate Elevated diastolic blood pressure Decreased body temperature Elevated respiratory rate Decreased pulse rate a. c. Which instructions does the nurse include in this client’s teaching? (Select all that apply. Refractory ANS: A An increase in heart and respiratory rates (heart rate first) from the client’s baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. Which manifestations does the nurse expect? (Select all that apply. c. B.

increased blood glucose. Decreased cardiac output b. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. and increased serum lactate. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply. 823 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) .” f. A client has septic shock. “Rinse your toothbrush in liquid laundry bleach. p. and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Increased cardiac output c.) a. Increased serum lactate f. DIF: Cognitive Level: Comprehension/Understanding REF: Table 39-5. The other parameters do not correlate with septic shock.” ANS: B. Increased blood glucose d. F Daily temperatures. washing dishes in hot sudsy water or a dishwasher. C. E. “Wash dishes with hot sudsy water. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning 3. This population is not restricted from pets but is only advised not to change pet litter boxes. Decreased blood glucose e. E Septic shock manifests with decreased cardiac output.e. Decreased serum lactate ANS: A.