Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) - Shock and Multiple Organ Dysfunction Syndrome

Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) - Shock and Multiple Organ Dysfunction Syndrome Related

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When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal?

  • A. Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping.
  • B. Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
  • C. Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature.
  • D. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.
Correct Answer: D

Rationale: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.

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A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patients plan of care while the patient is ventilated?

  • A. Performing frequent oral care
  • B. Maintaining the patient in a supine position
  • C. Suctioning the patient every 15 minutes unless contraindicated
  • D. Administering prophylactic antibiotics, as ordered
Correct Answer: A

Rationale: Nursing interventions that reduce the incidence of VAP must also be implemented. These include frequent oral care, aseptic suction technique, turning, and elevating the head of the bed at least 30 degrees to prevent aspiration. Suctioning should not be excessively frequent and prophylactic antibiotics are not normally indicated.

A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?

  • A. Anaphylactic shock
  • B. Neurogenic shock
  • C. Septic shock
  • D. Hypovolemic shock
Correct Answer: B

Rationale: Neurogenic shock can be caused by spinal cord injury. The patient will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patients risk of septic shock?

  • A. Apply an antibiotic ointment to the patients mucous membranes, as ordered.
  • B. Perform passive range-of-motion exercises unless contraindicated
  • C. Initiate total parenteral nutrition (TPN)
  • D. Remove invasive devices as soon as they are no longer needed
Correct Answer: D

Rationale: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.

The ICU nurse is caring for a patient in neurogenic shock following an overdose of antianxiety medication. When assessing this patient, the nurse should recognize what characteristic of neurogenic shock?

  • A. Hypertension
  • B. Cool, moist skin
  • C. Bradycardia
  • D. Signs of sympathetic stimulation
Correct Answer: C

Rationale: In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of 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.

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