Nokea
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.
You may also like to solve these questions
The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?
- A. Central venous pressure reflects the pressure in the right atrium or venae cavae.'
- B. A pulmonary artery pressure provides information about pressure on the left side of the heart.'
- C. The trend in central venous pressure is more helpful than isolated readings.'
- D. Pulmonary artery pressure and pulmonary capillary pressure is assessed by an inserted catheter.'
Correct Answer: B
Rationale: The most pertinent information to share with a new nurse is the information that the pulmonary artery pressure provides essential information about the effectiveness of left ventricle. The left ventricle is most pertinent to circulation. The other information is correct but not as pertinent.
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.
A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?
- A. Anaphylactic
- B. Neurogenic
- C. Septic
- D. Obstructive
Correct Answer: B
Rationale: Neurogenic shock results from an insult to the vasomotor center of the medulla or to the peripheral nerves that extend from the spinal cord to the blood vessels. The tone of the sympathetic nervous system is impaired, resulting in deceased arterial vascular resistance, vasodilation, and hypotension. Anaphylactic shock has vasodilation also as a key characteristic, along with increased capillary permeability, swelling of the airway, hives, and itching. Septic shock is associated with overwhelming bacterial infections. Obstructive shock is when there is an interference of blood flow in and out of the heart.
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
- A. Hormone antagonist drugs
- B. Antimetabolite drugs
- C. Adrenergic drugs
- D. Anticholinergic drugs
Correct Answer: C
Rationale: Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.
The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?
- A. Hemoglobin: $14.2 \mathrm{~g} / \mathrm{dL}$
- B. Potassium: $4.8 \mathrm{mEq} / \mathrm{L}$
- C. WBC: $42,000 / \mathrm{mm} 3$
- D. ESR: $19 \mathrm{~mm} /$ hour
Correct Answer: C
Rationale: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.