Nokea
The nurse is providing care for a patient who is in shock after massive blood loss from a workplace injury. The nurse recognizes that many of the findings from the most recent assessment are due to compensatory mechanisms. What is a compensatory mechanism to increase cardiac output during hypovolemic states?
- A. Third spacing of fluid
- B. Dysrhythmias
- C. Tachycardia
- D. Gastric hypermotility
Correct Answer: C
Rationale: Tachycardia is a primary compensatory mechanism to increase cardiac output during hypovolemic states. The third spacing of fluid takes fluid out of the vascular space. Gastric hypermotility and dysrhythmias would not increase cardiac output and are not considered to be compensatory mechanisms.
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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 team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply.
- A. Anaphylactic
- B. Hypovolemic
- C. Cardiogenic
- D. Septic
- E. Neurogenic
Correct Answer: A,D,E
Rationale: The varied mechanisms leading to the initial vasodilation in circulatory shock provide the basis for the further subclassification of shock into three types: septic shock, neurogenic shock, and anaphylactic shock. Hypovolemic and cardiogenic shock are not subclassifications of circulatory shock.
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.
The intensive care nurse caring for a patient in shock is planning assessments and interventions related to the patients nutritional needs. What physiologic process contributes to these increased nutritional needs?
- A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate (ATP)
- B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
- C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements
- D. The increase in GI peristalsis during shock and the resulting diarrhea
Correct Answer: C
Rationale: Nutritional support is an important aspect of care for patients in shock. Patients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.
In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances?
- A. Fluid volume circulating in the blood vessels decreases.
- B. There is an uncontrolled increase in cardiac output.
- C. Blood pressure regulation becomes irregular.
- D. The patient experiences tachycardia and a bounding pulse.
Correct Answer: A
Rationale: Hypovolemic shock is characterized by a decrease in intravascular volume. Cardiac output is decreased, blood pressure decreases, and pulse is fast, but weak.