Nokea
A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?
- A. Liver dysfunction
- B. Organ damage
- C. Weight loss
- D. Unsteady gait
Correct Answer: B
Rationale: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.
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The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, 'What causes the body to go into shock?' Given the client's condition, which statement is most correct?
- A. The client is in shock because the blood volume has decreased in the system.'
- B. The client is in shock because the heart is unable to circulate the body fluids.'
- C. The client is in shock because your loved one is not responding and brain dead.'
- D. The client is in shock because all peripheral blood vessels have massively dilated.'
Correct Answer: A
Rationale: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
- A. A rapid, bounding pulse
- B. A slow but steady pulse
- C. A weak and thready pulse
- D. A slow and imperceptible pulse
Correct Answer: A
Rationale: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.
The nurse is caring for a client who does not accept blood or blood products. Which nursing action(s) conserves blood? Select all that apply.
- A. Administer medication to stimulate bone marrow.
- B. Draw minimum volume of blood for diagnostic tests.
- C. Administer plasma to expand intravascular volume.
- D. Reinfuse the client's own blood via closed circuit container.
- E. Administer factor VIII to stimulate coagulation process.
- F. Administer blood product only in an emergency.
Correct Answer: A,B,D,E
Rationale: The client that does not accept blood or blood products will accept medications to stimulate the natural production of cells or cause the current cells to last. Also measures that use the blood product wisely are stressed. Plasma is a component of the blood so the client would not permit the infusion and will not consent to blood products in an emergency.
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
- A. Hormone antagonist drugs
- B. Antimetabolite drugs
- C. Adrenergic drugs
- D. Anticholinergic drugs
Correct Answer: C
Rationale: Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.
The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
- A. A rise in blood count
- B. Alertness in level of consciousness
- C. Increased heart rate
- D. Pulse oxygenation level of $92 \%$
Correct Answer: B
Rationale: In hypovolemic shock, the volume of extracellular fluid is significantly diminished because of lost or reduced blood or plasma. Circulation is impaired. Alertness in the level of consciousness indicates improved circulation and thus oxygenation to the brain. A documented rise in blood count is promising unless tissue damage has already occurred. A decrease in heart rate would mean the heart is no longer struggling to circulate blood to meet tissue needs. A pulse oxygenation level of $92 \%$ is a good sign of available oxygen for the tissue.