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The nurse in the ICU is caring for a 47-year-old, obese male patient who is in shock following a motor vehicle accident. The nurse is aware that patients in shock possess excess energy requirements. What would be the main challenge in meeting this patients elevated energy requirements during prolonged rehabilitation?
- A. Loss of adipose tissue
- B. Loss of skeletal muscle
- C. Inability to convert adipose tissue to energy
- D. Inability to maintain normal body mass
Correct Answer: B
Rationale: Nutritional energy requirements are met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle greatly prolongs the patients recovery time. Loss of adipose tissue, the inability to convert adipose tissue to energy, and the inability to maintain normal body mass are not main concerns in meeting nutritional energy requirements for this patient.
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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.
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.
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patients plan of care while the patient is ventilated?
- A. Performing frequent oral care
- B. Maintaining the patient in a supine position
- C. Suctioning the patient every 15 minutes unless contraindicated
- D. Administering prophylactic antibiotics, as ordered
Correct Answer: A
Rationale: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurses assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses analysis of these data should lead to what preliminary conclusion?
- A. The patient is in the compensatory stage of shock.
- B. The patient is in the progressive stage of shock.
- C. The patient will stabilize and be released by tomorrow.
- D. The patient is in the irreversible stage of shock.
Correct Answer: A
Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Patients display the often-described fight or flight response. The body shunts blood from organs such as the skin, kidneys, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the patients chance of survival is low and he will certainly not be released within 24 hours. If the patient were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.
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.