Nokea
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.
You may also like to solve these questions
The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, $97.2^{\circ} \mathrm{F}$; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, $102 / 78 \mathrm{~mm} \mathrm{Hg}$; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?
- A. Within normal limits
- B. Thready
- C. 24
- D. Palpable
Correct Answer: C
Rationale: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24 . The pulse pressure does not report quality of the pulse.
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
- A. Endotoxins in the system
- B. Limited gas exchange
- C. Brain death
- D. Multiple organ failure
Correct Answer: D
Rationale: In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a 'point of no return' despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
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.
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 in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
- A. A rapid, bounding pulse
- B. A slow but steady pulse
- C. A weak and thready pulse
- D. A slow and imperceptible pulse
Correct Answer: A
Rationale: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.