ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 17 : Caring for Clients in Shock Questions
Question 1 of 5
A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?
Correct Answer: D
Rationale: The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, and pH decreases, causing metabolic acidosis.
Therefore, 'compensation', 'irreversible', and 'early' are incorrect.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?
Correct Answer: B
Rationale: Neurogenic shock results from an insult to the vasomotor center of the medulla or to the peripheral nerves that extend from the spinal cord to the blood vessels. The tone of the sympathetic nervous system is impaired, resulting in deceased arterial vascular resistance, vasodilation, and hypotension. Anaphylactic shock has vasodilation also as a key characteristic, along with increased capillary permeability, swelling of the airway, hives, and itching. Septic shock is associated with overwhelming bacterial infections. Obstructive shock is when there is an interference of blood flow in and out of the heart.
Question 5 of 5
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?
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.