Nokea
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.
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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.
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
- A. Blanch the nailbeds.
- B. Inspect the conjunctiva.
- C. Note dullness in skin color.
- D. Assess the earlobe.
Correct Answer: B
Rationale: In clients with highly pigmented skin, cyanosis is more accurately detected by inspecting the conjunctiva and oral mucous membranes. The other options do not provide the best assessment for cyanosis.
Which compensatory mechanism, during the first stage of shock, does the nurse identify as responsible for stabilization of fluid balance?
- A. Catecholamines
- B. Corticosteroid hormones
- C. Renin-angiotensin
- D. Aldosterone
Correct Answer: B
Rationale: Corticosteroids, including mineral corticoids such as aldosterone, conserve sodium and promote potassium excretion. This plays an active role in controlling sodium and water balance. Catecholamines impact the sympathetic nervous system. The renin-angiotensin-aldosterone system impacts blood volume.
The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
- A. Serum thyroid level findings
- B. Arterial blood gas (ABG) findings
- C. Red blood cells (RBCs) and hemoglobin count findings
- D. White blood cell count findings
Correct Answer: B
Rationale: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Serum thyroid level findings do not help determine the presence of hypoxemia or metabolic acidosis.
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?
- A. Slow the heart rate
- B. Increase the force of myocardial contraction
- C. Depress the central nervous system
- D. Dilate the bronchial tree
Correct Answer: B
Rationale: The nurse realizes that when administering a medication with a positive inotropic effect, the medication increases the force of heart muscle contraction. The heart rate increases not decreases. The central nervous system is not depressed nor is there a dilation of the bronchial tree.