Chapter 37: Care of Patients with Shock

Chapter 37: Care of Patients with Shock

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client’s mean arterial pressure (MAP)?
   1. It causes vasoconstriction and increased MAP.
   2. Lower blood volume lowers MAP.
   3. There is no direct correlation to MAP.
   4. It raises cardiac output and MAP.

ANS:   B

Lower blood volume will decrease MAP. The other answers are not accurate.

DIF:     Remembering/Knowledge                 REF: 740                     KEY: Mean arterial blood pressure| shock                                                            MSC:             Integrated Process: Nursing Process: Assessment                                       NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?
   1. Ask if the client needs pain medication.
   2. Assess the client’s tissue perfusion further.
   3. Document the findings in the client’s chart.
   4. Increase the rate of the client’s IV infusion.

ANS:   B

Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

DIF:     Applying/Application                         REF: 743                     KEY: Shock| perfusion| nursing assessment                                                                   MSC:             Integrated Process: Nursing Process: Assessment                                       NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
   1. Client with a blood pressure change of 128/74 to 110/88 mm Hg
   2. Client with oxygen saturation unchanged at 94%
   3. Client with a pulse change of 100 to 88 beats/min
   4. Client with urine output of 40 mL/hr for the last 2 hours

ANS:   A

This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

DIF:            Analyzing/Analysis                            REF:    743                   KEY: Shock| perfusion| nursing assessment                                                             MSC: Integrated Process: Nursing Process: Assessment                      NOT:                                                 Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
   1. Assess the client for pain or discomfort.
   2. Measure urine output from the catheter.
   3. Reposition the client to the unaffected side.
   4. Stay with the client and reassure him or her.

ANS:           B

Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

DIF:            Applying/Application                         REF:    743                   KEY: Shock| nursing assessment| renal system| delegation| unlicensed assistive personnel (UAP) MSC:    Integrated Process: Nursing Process: Assessment  NOT:                                  Client Needs Category: Safe and Effective Care Environment: Management of Care

5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
   1. “High glucose is common in shock and needs to be treated.”
   2. “Some of the medications we are giving are to raise blood sugar.”
   3. “The IV solution has lots of glucose, which raises blood sugar.”
   4. “The stress of this illness has made your spouse a diabetic.”

ANS:           A

High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not “made” the client diabetic.

DIF:            Understanding/Comprehension         REF:    754

KEY:          Shock| patient education| hyperglycemia| insulin| endocrine system

MSC:          Integrated Process: Teaching/Learning

NOT:          Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies