Nokea
The student nurse is being precepted in the ICU. The student is caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the re absorption and retention of fluid in the body?
- A. Activation of renin-angiotensin-aldosterone system
- B. Secretion of epinephrine and norepinephrine
- C. Production of antidiuretic hormone and corticosteroid hormones
- D. Release of catecholamines
Correct Answer: C
Rationale: Antidiuretic hormone (ADH) and corticosteroid hormones play an active role in controlling sodium and water balance. Both ADH and corticosteroid hormones promote fluid reabsorption and retention. The renin-angiotensin-aldosterone system is a mechanism that restores blood pressure (BP) when circulating volume is diminished. The release of catecholamines stimulates secretion of epinephrine and norepinephrine.
You may also like to solve these questions
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 critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?
- A. Decreased white blood cell count
- B. Increase in arterial oxygenation
- C. Decreased depressive symptoms
- D. Regulation of sodium and potassium
Correct Answer: B
Rationale: Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. Catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation, improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.
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 nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of $40 \mathrm{~mL}$ from the Foley catheter, which nursing action is most appropriate?
- A. Reposition the client and make sure there are no kinks in the catheter tubing.
- B. Notify the physician of the hourly output and encourage physician assessment.
- C. Record $40 \mathrm{~mL}$ as the hourly output.
- D. Notify the family of the urine output.
Correct Answer: C
Rationale: Urine output above $35 \mathrm{~mL} /$ hour or $500 \mathrm{~mL} /$ day indicates adequate kidney perfusion. The hourly output would be documented in the client record. There is no need to reposition the client or look for a kink because adequate amounts of urine is collecting in the tube. There is no need to notify the physician or family.
The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?
- A. Hemoglobin: $14.2 \mathrm{~g} / \mathrm{dL}$
- B. Potassium: $4.8 \mathrm{mEq} / \mathrm{L}$
- C. WBC: $42,000 / \mathrm{mm} 3$
- D. ESR: $19 \mathrm{~mm} /$ hour
Correct Answer: C
Rationale: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.