Chapter 9. Nursing Care of Patients in Shock

Chapter 9. Nursing Care of Patients in Shock

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____     1.   A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock?

a.	Respirations 18/min
b.	Heart rate 118 beats/min
c.	Temperature 98.6°F (37°C)
d.	Blood pressure 130/90 mm Hg

 

 

____     2.   A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient becomes anxious and irritable and bright red drainage appears through the nasogastric tube. The patient’s vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and respirations 28/minute. What should the nurse recognize as causing the changes in the patient’s vital signs?

a.	Early shock
b.	Patient anxiety
c.	Progressive shock
d.	Parasympathetic response

 

 

____     3.   A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the nurse recognize as the likely cause of acidosis?

a.	Hyperventilation
b.	Aerobic metabolism
c.	Inadequate ventilation
d.	Anaerobic metabolism

 

 

____     4.   A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output?

a.	Encourage oral fluids.
b.	Irrigate urinary catheter.
c.	Increase IV fluid infusion rate.
d.	Check urinary catheter for kinking.

 

 

____     5.   A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse recognize as the most likely cause of the patient’s oliguria?

a.	End-stage renal failure
b.	Secretion of aldosterone
c.	Inadequate oral fluid intake
d.	Obstructed urinary catheter

 

MULTIPLE CHOICE

 

1. ANS:  B

When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. A. C. D. These findings are all within normal limits and do not necessarily indicate manifestations of early shock.

 

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

 

2. ANS:  A

When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of early shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. B. C. D. The patient’s change in vital signs is not caused by anxiety, progressive shock, or a parasympathetic response.

 

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

 

3. ANS:  D

When cells are deprived of oxygen, they shift to anaerobic metabolism, resulting in the production of lactic acid. Unless the lactic acid is removed from the bloodstream, the blood will become increasingly acidic, resulting in metabolic acidosis. C. Inadequate ventilation leads to respiratory acidosis as CO₂ levels rise. A. Hyperventilation leads to respiratory alkalosis as CO₂ levels decrease. B. Aerobic metabolism is normal.

 

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

 

4. ANS:  D

Collecting data is the first step in critically thinking about a situation. In this case, the urine output is lower than normal, which could be due to several reasons. The initial action of the nurse should be to inspect the urinary catheter system for proper functioning. If the catheter system is inhibiting urine output, then that issue must be addressed to correct the situation. Other interventions will not help if the system is the cause. B. Catheter irrigation is invasive and breaks the sterile system. A. Oral fluids will not help if the system is kinked; also the patient is confused and so may not be able to take oral fluids safely, and an IV is infusing to hydrate the patient. C. An order is needed to increase the IV rate.

 

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

 

5. ANS:  B

Stimulation of the renin-angiotensin-aldosterone system from decreased cardiac output causes vasoconstriction and retention of sodium and water to decrease further fluid loss, resulting in oliguria. A. There is no evidence to support that the patient is in end-stage renal failure. C. Since the patient is in hypovolemic shock, it is unlikely that oral fluids are being provided. D. There is not enough information to support that a urinary catheter is kinked in this patient.

 

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis