The AGACNP is managing a patient in the ICU who is being treated for a pulmonary embolus. Initially the patient was stable, awake, alert, and oriented, but during the last several hours the patient has become increasingly lethargic. At change of shift, the oncoming staff nurse appreciates a profound change in the patients mental status from the day before. Vital signs and hemodynamic parameters are as follows BP 8854 mm Hg Pulse 110 bpm Respiratory rate 22 breaths per minute SaO2 93 on a 50 mask Systemic vascular resistance (SVR) 1600 dynes seccm5 Cardiac index 1.3 Lmin Pulmonary capillary wedge pressure (PCWP) 8 mm Hg This clinical picture is most consistent with which shock state?

Correct Answer: B

Rationale: The patient's presentation with low blood pressure, tachycardia, tachypnea, decreased oxygen saturation, and altered mental status is most consistent with distributive shock. Distributive shock is characterized by systemic vasodilation and decreased systemic vascular resistance (SVR), leading to inadequate perfusion of tissues and organs despite normal or high cardiac output. In this case, the low SVR (1600 dynes ∙ sec/cm5) and low blood pressure indicate vasodilation. The patient's pulmonary capillary wedge pressure (PCWP) of 8 mm Hg is not consistent with cardiogenic shock, where elevated PCWP would be expected. Additionally, there are no signs of obstructive shock, such as a history of pulmonary embolism but rather clinical findings that suggest distributive shock. Hypovolemic shock would typically present with signs of volume depletion and would be less likely in this patient with stable mental status initially.

Correct Answer: A

Rationale: An MRI (Magnetic Resonance Imaging) would be the most useful head imaging study in assessing for findings consistent with a history of abuse in this patient. MRI is superior to CT in detecting subtle changes in the brain, such as small hemorrhages, edema, or shearing injuries, which may be present in cases of physical abuse. In cases of suspected abuse, it is important to evaluate for both acute and chronic changes that may not be clearly visible on other imaging modalities. While CT scans can detect acute hemorrhages or fractures, they may miss more subtle findings that can be seen on MRI. Therefore, an MRI would provide a more comprehensive evaluation of the brain and surrounding structures in this case.

Correct Answer: B

Rationale: The patient's presentation with significant abdominal pain, tachycardia, tensely rigid abdomen, rebound tenderness, hypoactive and intermittent bowel sounds, and tympanic percussion of the entire abdomen is concerning for peritonitis. Peritonitis is inflammation of the peritoneum, which is the lining of the abdominal cavity. It is often caused by an infection or irritation, such as from a perforated bowel, which can lead to the leakage of bowel contents into the peritoneal cavity. The presentation of peritonitis includes severe abdominal pain, guarding, rebound tenderness, abdominal distension, and signs of systemic inflammation like tachycardia and fever. In this case, the lack of point tenderness to palpation and the absence of dullness over the upper quadrants make perforated bowel less likely, while the tense rigidity of the abdomen and rebound tenderness are more suggestive of diffuse peritonitis. Ischem

Correct Answer: A

Rationale: Persistent occipito-posterior position means the occiput fails to rotate forward.

Correct Answer: B

Rationale: Escherichia coli is the primary causative agent of pyelonephritis in pregnant women.