Nokea
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurses plan of care should include which of the following interventions?
- A. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good
- B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months
- C. Promoting communication with the patient and family along with addressing end-of-life issues
- D. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
Correct Answer: C
Rationale: Promoting communication with the patient and family is a critical role of the nurse with a patient in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patients wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the patient.
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A patient who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurses care planning during the administration of a vasoactive drug?
- A. The drug should be discontinued immediately after blood pressure increases.
- B. The drug dose should be tapered down once vital signs improve.
- C. The patient should have arterial blood gases drawn every 10 minutes during treatment.
- D. The infusion rate should be titrated according the patients subjective sensation of adequate perfusion.
Correct Answer: B
Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. Subjective assessment data are secondary to objective data. Arterial blood gases should be carefully monitored, but every 10-minute draws are not the norm.
A patient is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the patients mean arterial pressure (MAP) has fallen to 55 mm Hg. The nurse should gauge the onset of acute kidney injury by referring to what laboratory findings? Select all that apply.
- A. Blood urea nitrogen (BUN) level
- B. Urine specific gravity
- C. Alkaline phosphatase level
- D. Creatinine level
- E. Serum albumin level
Correct Answer: A,B,D
Rationale: Acute kidney injury (AKI) is characterized by an increase in BUN and serum creatinine levels, fluid and electrolyte shifts, acid-base imbalances, and a loss of the renal-hormonal regulation of BP. Urine specific gravity is also affected. Alkaline phosphatase and albumin levels are related to hepatic function.
A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem?
- A. Blood is shunted from vital organs to peripheral areas of the body.
- B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
- C. Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
- D. Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
Correct Answer: B
Rationale: Shock is a life-threatening condition with a variety of underlying causes. Shock is caused when the cells have a lack of adequate blood supply and are deprived of oxygen and nutrients. In cases of shock, blood is shunted from peripheral areas of the body to the vital organs. Hemorrhage and decreased blood volume are associated with some, but not all, types of shock.
When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal?
- A. Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping.
- B. Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
- C. Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature.
- D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
Correct Answer: D
Rationale: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.
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.