Nokea
A critical care nurse is aware of similarities and differences between the treatments for different types of shock. Which of the following interventions is used in all types of shock?
- A. Aggressive hypoglycemic control
- B. Administration of hypertonic IV fluids
- C. Early provision of nutritional support
- D. Aggressive antibiotic therapy
Correct Answer: C
Rationale: Nutritional support is necessary for all patients who are experiencing shock. Hyperglycemic (not hypoglycemic) control is needed for many patients. Hypertonic IV fluids are not normally utilized and antibiotics are necessary only in patients with septic shock.
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Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring?
- A. Urinary output increases
- B. Skin becomes warm and dry
- C. Adventitious lung sounds occur in the upper airway
- D. Heart and respiratory rates are elevated
Correct Answer: D
Rationale: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.
The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
- A. Increased urine output
- B. Decreased heart rate
- C. Hyperactive bowel sounds
- D. Cool, clammy skin
Correct Answer: D
Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patients skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurses plan of care should include which of the following interventions?
- A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good
- B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months
- C. Promoting communication with the patient and family along with addressing end-of-life issues
- D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
Correct Answer: C
Rationale: Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patients wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.
The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient?
- A. It promotes coping and slows catecholamine release.
- B. It stimulates the patient so he or she is more alert.
- C. It decreases gastric secretions.
- D. It dilates the blood vessels.
Correct Answer: D
Rationale: For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patients anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion?
- A. The patient is in the compensatory stage of shock.
- B. The patient is in the progressive stage of shock.
- C. The patient will stabilize and be released by tomorrow.
- D. The patient is in the irreversible stage of shock.
Correct Answer: A
Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patients chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.