Nokea
The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the parent. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child?
- A. The child is having an allergic reaction and going into cardiogenic shock.
- B. The child is having an allergic reaction and going into anaphylactic shock.
- C. The child is having an allergic reaction and going into neurogenic shock.
- D. The child is having an allergic reaction and going into obstructive shock.
Correct Answer: B
Rationale: Anaphylactic shock is a severe allergic reaction that follows exposure to a substance to which a person is extremely sensitive (see Ch. 34). Common allergic substances include bee venom, latex, fish, nuts, and penicillin. The body's immune response to the allergic substance causes mast cells in the connective tissues, bronchi, and gastrointestinal tract to release histamine and other chemicals. The results are vasodilatation, increased capillary permeability accompanied by swelling of the airway and subcutaneous tissues, hypotension, and hives or an itchy rash. Cardiogenic shock, neurogenic shock, and obstructive shock would not begin with vasodilation, swelling of the airway, and hives.
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The nurse is caring for an older adult client receiving dopamine therapy for the treatment of shock. For which complication should the nurse monitor?
- A. Hypoglycemia
- B. Water intoxication
- C. Photophobia
- D. Rapid increase in blood pressure
Correct Answer: D
Rationale: The nurse should monitor an older adult client receiving dopamine therapy for the treatment of shock for a rapid increase in blood pressure. Hyperglycemia, not hypoglycemia, is a potential complication of dopamine therapy. Water intoxication is a potential complication of vasopressin. Photophobia is a potential complication of sympathomimetic vasopressor agents.
The nurse is caring for a client with shock accompanied by lung congestion. How would the nurse position this client?
- A. Completely supine
- B. Low Fowler's with legs flat
- C. Supine with lower extremities raised to approximately $45^{\circ}$
- D. Semi-Fowler's with lower extremities raised to approximately $15^{\circ}$
Correct Answer: D
Rationale: For a client with shock accompanied by lung congestion, the nurse should raise the client's upper body to approximately $45^{\circ}$ and lower extremities to approximately $15^{\circ}$. Elevating the upper body lowers the diaphragm and provides more room for lung expansion and gas exchange. Elevating the head reduces intracranial pressure. Elevating the legs promotes blood perfusion to the heart, lungs, and brain.
The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock?
- A. Obstructive
- B. Hypovolemic
- C. Carcinogenic
- D. Distributive
Correct Answer: D
Rationale: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such condition as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?
- A. Decreased white blood cell count
- B. Increase in arterial oxygenation
- C. Decreased depressive symptoms
- D. Regulation of sodium and potassium
Correct Answer: B
Rationale: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. Catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation, improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
- A. Place a cool compress on head.
- B. Elevate the legs higher than the heart.
- C. Shake the client to arouse.
- D. Cover the client with a blanket.
Correct Answer: B
Rationale: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.