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 planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
Correct Answer: C
Rationale: Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.
Question 2 of 5
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified by the neighbor. Which nursing action is helpful while waiting for the ambulance?
Correct Answer: B
Rationale: The client has shallow respiration and a weak pulse implying limited circulation and gas exchange. Most helpful would be to elevate the legs higher than the heart to promote blood perfusion to the heart, lungs, and brain. A cool compress would not be helpful nor would shaking the client to arouse. A client can be covered with a blanket, but this is not the most helpful.
Question 3 of 5
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
Correct Answer: D
Rationale: In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a 'point of no return' despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
Question 4 of 5
A nurse educator is teaching students the types of shock and associated causes. Which combination(s) of shock type and causative factors is correct? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock occurs when the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma. Obstructive shock occurs when there is interference in blood flow through the heart. Cardiogenic shock occurs when the heart is ineffective in pumping possibly due to a myocardial infarction. Anaphylactic shock occurs from an allergen such as nuts. Septic shock occurs from a bacterial infection. Neurogenic shock results from an insult to the vasomotor center in the medulla or peripheral nerves.
Question 5 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.