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The nurse, a member of the health care team in the ED, is caring for a patient who is determined to be in the irreversible stage of shock. What would be the most appropriate nursing intervention?
- A. Provide opportunities for the family to spend time with the patient, and help them to understand the irreversible stage of shock.
- B. Inform the patients family immediately that the patient will likely not survive to allow the family time to make plans and move forward.
- C. Closely monitor fluid replacement therapy, and inform the family that the patient will probably survive and return to normal life.
- D. Protect the patients airway, optimize intravascular volume, and initiate the early rehabilitation process.
Correct Answer: A
Rationale: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Providing opportunities for the family to spend time with the patient and helping them to understand the irreversible stage of shock is the best intervention. Informing the patients family early that the patient will likely not survive does allow the family to make plans and move forward, but informing the family too early will rob the family of hope and interrupt the grieving process. The chance of surviving the irreversible (or refractory) stage of shock is very small, and the nurse needs to help the family cope with the reality of the situation. With the chances of survival so small, the priorities shift from aggressive treatment and safety to addressing the end-of-life issues.
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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.
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.
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.
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 receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?
- A. Anaphylactic shock
- B. Neurogenic shock
- C. Septic shock
- D. Hypovolemic shock
Correct Answer: B
Rationale: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.