Nokea
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.
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In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances?
- A. Fluid volume circulating in the blood vessels decreases.
- B. There is an uncontrolled increase in cardiac output.
- C. Blood pressure regulation becomes irregular.
- D. The patient experiences tachycardia and a bounding pulse.
Correct Answer: A
Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.
The ICU nurse is caring for a patient in hypovolemic shock following a postpartum hemorrhage. For what serious complication of treatment should the nurse monitor the patient?
- A. Anaphylaxis
- B. Decreased oxygen consumption
- C. Abdominal compartment syndrome
- D. Decreased serum osmolality
Correct Answer: C
Rationale: Abdominal compartment syndrome (ACS) is a serious complication that may occur when large volumes of fluid are administered. The scenario does not describe an antigen-antibody reaction of any type. Decreased oxygen consumption by the body is not a concern in hypovolemic shock. With a decrease in fluids in the intravascular space, increased serum osmolality would occur.
A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurses care planning during the administration of a vasoactive drug?
- A. The drug should be discontinued immediately after blood pressure increases.
- B. The drug dose should be tapered down once vital signs improve.
- C. The patient should have arterial blood gases drawn every 10 minutes during treatment.
- D. The infusion rate should be titrated according the patients subjective sensation of adequate perfusion.
Correct Answer: B
Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every 10-minute draws are not the norm.
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 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.