ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 17 Questions
Question 1 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 2 of 5
The nurse is caring for an older adult client receiving dopamine therapy for the treatment of shock. For which complication should the nurse monitor?
Correct Answer: D
Rationale: The nurse should monitor an older adult client receiving dopamine therapy for the treatment of shock for a rapid increase in blood pressure. Hyperglycemia, not hypoglycemia, is a potential complication of dopamine therapy. Water intoxication is a potential complication of vasopressin. Photophobia is a potential complication of sympathomimetic vasopressor agents.
Question 3 of 5
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?
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.
Question 4 of 5
Which compensatory mechanism, during the first stage of shock, does the nurse identify as responsible for stabilization of fluid balance?
Correct Answer: B
Rationale: Corticosteroids, including mineral corticoids such as aldosterone, conserve sodium and promote potassium excretion. This plays an active role in controlling sodium and water balance. Catecholamines impact the sympathetic nervous system. The renin-angiotensin-aldosterone system impacts blood volume.
Question 5 of 5
The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?
Correct Answer: C
Rationale: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.