Nokea
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.
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The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
- A. A rise in blood count
- B. Alertness in level of consciousness
- C. Increased heart rate
- D. Pulse oxygenation level of $92 \%$
Correct Answer: B
Rationale: In hypovolemic shock, the volume of extracellular fluid is significantly diminished because of lost or reduced blood or plasma. Circulation is impaired. Alertness in the level of consciousness indicates improved circulation and thus oxygenation to the brain. A documented rise in blood count is promising unless tissue damage has already occurred. A decrease in heart rate would mean the heart is no longer struggling to circulate blood to meet tissue needs. A pulse oxygenation level of $92 \%$ is a good sign of available oxygen for the tissue.
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 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.
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
- A. Blanch the nailbeds.
- B. Inspect the conjunctiva.
- C. Note dullness in skin color.
- D. Assess the earlobe.
Correct Answer: B
Rationale: In clients with highly pigmented skin, cyanosis is more accurately detected by inspecting the conjunctiva and oral mucous membranes. The other options do not provide the best assessment for cyanosis.
The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?
- A. 1:01
- B. 2:01
- C. 3:01
- D. 4:01
Correct Answer: C
Rationale: Usually, a ratio of $3 \mathrm{~L}$ of fluid is administered for every $1 \mathrm{~L}$ of fluid lost.