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An adult patient has survived an episode of shock and will be discharged home to finish the recovery phase of his disease process. The home health nurse plays an integral part in monitoring this patient. What aspect of his care should be prioritized by the home health nurse?
- A. Providing supervision to home health aides in providing necessary patient care
- B. Assisting the patient and family to identify and mobilize community resources
- C. Providing ongoing medical care during the familys rehabilitation phase
- D. Reinforcing the importance of continuous assessment with the family
Correct Answer: B
Rationale: The home care nurse reinforces the importance of continuing medical care and helps the patient and family identify and mobilize community resources. The home health nurse is part of a team that provides patient care in the home. The nurse does not directly supervise home health aides. The nurse provides nursing care to both the patient and family, not just the family. The nurse performs continuous and ongoing assessment of the patient; he or she does not just reinforce the importance of that assessment.
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The acute care nurse is providing care for an adult patient who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of the ADH during hypovolemic shock?
- A. Increased hunger
- B. Decreased thirst
- C. Decreased urinary output
- D. Increased capillary perfusion
Correct Answer: C
Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary perfusion decreases as the body shunts blood away from the periphery and to the vital organs.
The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patients nutritional needs. What physiologic process contributes to these increased nutritional needs?
- A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP)
- B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
- C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements
- D. The increase in GI peristalsis during shock and the resulting diarrhea
Correct Answer: C
Rationale: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.
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.
A patient is responding poorly to interventions aimed at treating shock and appears to be transitioning to the irreversible stage of shock. What action should the intensive care nurse include during this phase of the patients care?
- A. Communicate clearly and frequently with the patients family.
- B. Taper down interventions slowly when the prognosis worsens.
- C. Transfer the patient to a subacute unit when recovery appears unlikely.
- D. Ask the patients family how they would prefer treatment to proceed.
Correct Answer: A
Rationale: As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patients care, for the family to see, touch, and talk to the patient. The onus should not be placed on the family to guide care, however. Interventions are not normally reduced gradually when they are deemed ineffective; instead, they are discontinued when they appear futile. The patient would not be transferred to a subacute unit.
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.