Nokea
A triage nurse in the ED is on shift when a grandfather carries his 4-year-old grandson into the ED. The child is not breathing, and the grandfather states the boy was stung by a bee in a nearby park while they were waiting for the boys mother to get off work. Which of the following would lead the nurse to suspect that the boy is experiencing anaphylactic shock?
- A. Rapid onset of acute hypertension
- B. Rapid onset of respiratory distress
- C. Rapid onset of neurologic compensation
- D. Rapid onset of cardiac arrest
Correct Answer: B
Rationale: Characteristics of severe anaphylaxis usually include rapid onset of hypotension, neurologic compromise, and respiratory distress. Cardiac arrest can occur if prompt treatment is not provided.
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A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply.
- A. Hypovolemia
- B. Difficulty breathing
- C. Cardiovascular overload
- D. Pulmonary edema
- E. Hypoglycemia
Correct Answer: B,C,D
Rationale: Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.
A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patients mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
- A. Blood urea nitrogen (BUN) level
- B. Urine specific gravity
- C. Alkaline phosphatase level
- D. Creatinine level
- E. Serum albumin level
Correct Answer: A,B,D
Rationale: Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function.
The intensive care nurse is responsible for the care of a patient with shock. What cardiac signs or symptoms would suggest to the nurse that the patient may be experiencing acute organ dysfunction? Select all that apply.
- A. Drop in systolic blood pressure of 40 mm Hg from baselines
- B. Hypotension that responds to bolus fluid resuscitation
- C. Exaggerated response to vasoactive medications
- D. Serum lactate >4 mmol/L
- E. Mean arterial pressure (MAP) of 65 mm Hg
Correct Answer: A,D,E
Rationale: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg, mean arterial pressure (MAP) <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.
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 providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states?
- A. Third spacing of fluid
- B. Dysrhythmias
- C. Tachycardia
- D. Gastric hypermotility
Correct Answer: C
Rationale: Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.