ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 17 : Caring for Clients in Shock Questions
Question 1 of 5
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.
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.
Question 2 of 5
The nurse is caring for a client who does not accept blood or blood products. Which nursing action(s) conserves blood? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The client that does not accept blood or blood products will accept medications to stimulate the natural production of cells or cause the current cells to last. Also measures that use the blood product wisely are stressed. Plasma is a component of the blood so the client would not permit the infusion and will not consent to blood products in an emergency.
Question 3 of 5
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?
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.
Question 4 of 5
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
Correct Answer: C
Rationale: Adrenergic drugs are the main medications used to treat shock due to their action on the receptors of the sympathetic nervous system.
Question 5 of 5
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?
Correct Answer: A
Rationale: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.