Nokea
A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?
- A. Anaphylactic shock
- B. Neurogenic shock
- C. Septic shock
- D. Hypovolemic shock
Correct Answer: B
Rationale: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.
You may also like to solve these questions
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply.
- A. Anaphylactic
- B. Hypovolemic
- C. Cardiogenic
- D. Septic
- E. Neurogenic
Correct Answer: A,D,E
Rationale: The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.
The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patients elevated energy requirements during prolonged rehabilitation?
- A. Loss of adipose tissue
- B. Loss of skeletal muscle
- C. Inability to convert adipose tissue to energy
- D. Inability to maintain normal body mass
Correct Answer: B
Rationale: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patients recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this patient.
The nurse is caring for a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the physician will promptly order the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock?
- A. Lactated Ringers
- B. Albumin
- C. Dextran
- D. 3% NaCl
Correct Answer: A
Rationale: Crystalloids are electrolyte solutions used for the treatment of hypovolemic shock. Lactated Ringers and0.9\%$ sodium chloride are isotonic crystalloid fluids commonly used to manage hypovolemic shock. Dextran and albumin are colloids, but Dextran, even as a colloid, is not indicated for the treatment of hypovolemic shock.3\% \mathrm{NaCl}$ is a hypertonic solution and is not isotonic.
A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem?
- A. Blood is shunted from vital organs to peripheral areas of the body.
- B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
- C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
- D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
Correct Answer: B
Rationale: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.
The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock?
- A. Elevated systolic blood pressure
- B. Elevated mean arterial pressure (MAP)
- C. Shallow, rapid respirations
- D. Bradycardia
Correct Answer: C
Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.