Nokea
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
- A. Limit interaction with visitors.
- B. Avoid heavy meals.
- C. Maintain activity restriction to bedrest.
- D. Arrange personal care supplies nearby.
Correct Answer: C
Rationale: Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.
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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 nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?
- A. Liver dysfunction
- B. Organ damage
- C. Weight loss
- D. Unsteady gait
Correct Answer: B
Rationale: When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.
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 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.
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.