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The nurse is caring for the client with massive blood loss from a gunshot wound, and type-specific blood is currently not available for transfusion. With little time to spare, which blood type does the nurse infuse?
- A. Type A+
- B. Type B+
- C. Type A/B-
- D. Type O-
Correct Answer: D
Rationale: When type-specific blood is not available and a transfusion is required, type $\mathrm{O}-$ blood is infused. Type A+, B+, and Type A/B- are not infused when type-specific blood is not available.
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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 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.
The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessment(s) that signal early signs of the decompensation stage? Select all that apply.
- A. Vital signs
- B. Nutrition
- C. Skin color
- D. Gait
- E. Urine output
- F. Peripheral pulses
Correct Answer: A,C,E,F
Rationale: Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys, and peripheral pulses all provide assessment data relating blood volume and circulation.
The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the different categories of shock. Which of the following is a category of shock?
- A. Hypervolemic
- B. Distributive
- C. Restrictive
- D. Cardiotonic
Correct Answer: B
Rationale: The four main categories of shock are hypovolemic, circulatory (distributive), obstructive, and cardiogenic, depending on the cause. Distributive, restrictive, and cardiotonic are not categories of shock.
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, 'What causes the body to go into shock?' Given the client's condition, which statement is most correct?
- A. The client is in shock because the blood volume has decreased in the system.'
- B. The client is in shock because the heart is unable to circulate the body fluids.'
- C. The client is in shock because your loved one is not responding and brain dead.'
- D. The client is in shock because all peripheral blood vessels have massively dilated.'
Correct Answer: A
Rationale: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.