Nokea
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.
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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.
The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient?
- A. It promotes coping and slows catecholamine release.
- B. It stimulates the patient so he or she is more alert.
- C. It decreases gastric secretions.
- D. It dilates the blood vessels.
Correct Answer: D
Rationale: For patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patients anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.
Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression. As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring?
- A. Urinary output increases
- B. Skin becomes warm and dry
- C. Adventitious lung sounds occur in the upper airway
- D. Heart and respiratory rates are elevated
Correct Answer: D
Rationale: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the patient begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., renal failure, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.
The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
- A. Increased urine output
- B. Decreased heart rate
- C. Hyperactive bowel sounds
- D. Cool, clammy skin
Correct Answer: D
Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the patients skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.
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.