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The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patients heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess?
- A. Dysrhythmias
- B. Increase in blood pressure
- C. Increase in heart rate
- D. Decrease in oxygen demands
Correct Answer: A
Rationale: Cardiogenic shock occurs when the hearts ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not cause increased blood pressure, increased heart rate, or a decrease in oxygen demands.
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The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock?
- A. Elevated systolic blood pressure
- B. Elevated mean arterial pressure (MAP)
- C. Shallow, rapid respirations
- D. Bradycardia
Correct Answer: C
Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.
The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention?
- A. Reviewing the cause of shock and prioritizing the patients psychosocial needs
- B. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
- C. Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive
- D. Promoting the patients coping skills in an effort to better deal with the physiologic changes accompanying shock
Correct Answer: B
Rationale: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health.
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.
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.
An 11-year-old boy has been brought to the ED by his teacher, who reports that the boy may be having a really bad allergic reaction to peanuts after trading lunches with a peer. The triage nurses rapid assessment reveals the presence of respiratory and cardiac arrest. What interventions should the nurse prioritize?
- A. Establishing central venous access and beginning fluid resuscitation
- B. Establishing a patent airway and beginning cardiopulmonary resuscitation
- C. Establishing peripheral IV access and administering IV epinephrine
- D. Performing a comprehensive assessment and initiating rapid fluid replacement
Correct Answer: B
Rationale: If cardiac arrest and respiratory arrest are imminent or have occurred, CPR is performed. As well, a patent airway is an immediate priority. Epinephrine is not withheld pending IV access and fluid resuscitation is not a priority.