Question 1

The nurse explains that pericardial tamponade and pulmonary embolus can place the patient at risk for ______________ shock.

Accepted Answer

Obstructive
Obstructive shock can result from pericardial tamponade or pulmonary embolus.

Question 2

The nurse explains to a concerned family member about the purpose of some of the interventions for systemic inflammatory response syndrome (SIRS),which is:

Accepted Answer

A)   Applying a MAST garment to promote and conserve body heat.
B)   Inserting an IABP to decrease fluid leaking into the extravascular space.
C)   Maintaining strict isolation to prevent an overlying bacterial infection.
D)   Aggressively treating to support the multiple failing organs. D

Question 3

Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock,shock itself results from failure of which system?

Accepted Answer

A)   Circulatory
B)   Endocrine
C)   Neurologic
D)   Respiratory A

Question 4

An older Japanese patient in progressive shock lingers on the verge of death.In general,the patient's cultural background dictates that the medical team should:

Accepted Answer

A)   Allow any and all cultural rituals at the bedside.
B)   Encourage the family to talk to the patient who can be comforted by their familiar voices.
C)   Restrict the ministrations of the folk healer.
D)   Suggest that small children not see the patient.

Question 5

In treating a person outside of a medical facility,the nurse knows that immediate circulatory support for the vital organs must begin as quickly as possible because,without oxygen,the brain cells will begin to die in how many minutes?

Accepted Answer

A)   4
B)   6
C)   14
D)   24

Question 6

The nurse explains that the minimal acceptable hourly urine output for the patient in shock who weighs 220 pounds is ____________________.

Accepted Answer

The answer of The nurse explains that the minimal acceptable...

Question 7

While shopping in the mall,the nurse sees a lady suddenly fall to the floor.On immediate assessment,the nurse realizes she is not in cardiac arrest and has no need for cardiopulmonary resuscitation (CPR).The immediate actions by the nurse are to:

Accepted Answer

A)   Check the pulse and respirations, and call for a blood pressure cuff.
B)   Check the pulse, respirations, skin color, and temperature.
C)   Call for help and check the pulse, respiration, and mental status.
D)   Ask someone to help place large blankets or coats under her legs and trunk.

Question 8

The nurse explains that when shock forces the body into anaerobic metabolism,organ damage is caused by a product of that metabolism,which is ____________________.

Accepted Answer

The answer of The nurse explains that when shock forces...

Question 9

In the treatment of the progressive stage of shock,the nurse would anticipate the use of drugs to bring about a(n):

Accepted Answer

A)   Increase in cardiac output
B)   Decrease in blood pressure
C)   Decrease in urine output
D)   Lower temperature

Question 10

The nurse is aware that immobility and insertion of urinary catheters,although therapeutic,also places the patient at risk for _________________________.

Accepted Answer

The answer of The nurse is aware that immobility and...

Question 11

The nurse caring for a patient who has a cervical spine injury immediately documents and reports the assessment of progressive hypotension as a sign of probable:

Accepted Answer

A)   Anaphylaxis
B)   Respiratory alkalosis
C)   Multiple organ dysfunction syndrome (MODS) 
D)   Neurogenic shock

Question 12

The nurse reviews the four types of shock,which are:

Accepted Answer

A)   Multiple organ, cardiogenic, renal, and anaphylactic
B)   Cardiogenic, renal, hypovolemic, and septic
C)   Renal, hypervolemic, obstructive shock, and neurogenic
D)   Hypovolemic, cardiogenic, obstructive shock, and vasogenic

Question 13

The nurse explains that the use of medical antishock trousers (MAST)garment compress the legs and abdomen to:

Accepted Answer

A)   Help restore cellular perfusion.
B)   Decrease internal hemorrhage.
C)   Cool the patient to create less metabolic demand.
D)   Apply pressure during the systole phase and relax pressure during the diastole phase.

Question 14

One of the most important assessments that the nurse makes is to check urine output.The value that objectively validates minimal acceptable renal perfusion for the average-size person is:

Accepted Answer

A)   0.5 ml/kg/hr
B)   0.5 ml/lb/hr
C)   1 ml/lb/hr
D)   0.2 ml/kg/hr

Question 15

The licensed practical/vocational nurse (LPN/LVN),assisting in developing a nursing care plan for a patient in shock,would include the nursing diagnosis of:

Accepted Answer

A)   Increased cardiac output, related to hypertension
B)   Increased cardiac output, related to hypotension
C)   Decreased cardiac output, related to hypovolemia
D)   Decreased cardiac output, related to hypertension

Question 16

The stages of shock proceed in a definite sequence.What is the correct order?

Accepted Answer

A)   Progressive, compensatory, refractory
B)   Refractory, progressive, compensatory
C)   Compensatory, progressive, refractory
D)   Distributive, compensatory, refractory

Question 17

When speaking to the family of a 65-year-old Hispanic woman,the nurse will address most conversation to the:

Accepted Answer

A)   66-year-old husband
B)   Entire family, in general
C)   42-year-old daughter (oldest child) 
D)   40-year-old son (only son)

Question 18

Nursing interventions to help the patient cope with decreased cardiac output include which one of the following?

Accepted Answer

A)   Dovetailing nursing care tasks allows rest periods for the patient.
B)   Maintaining enough cover prevents the patient from shivering.
C)   Turning, coughing, deep-breathing, and ambulating the patient every 2 hours reduce the risk of embolism.
D)   Administering analgesics cautiously.

Question 19

The nurse assessing a patient who is in shock is aware that one common sign that the nurse will find,regardless of the cause of the shock,is:

Accepted Answer

A)   Skin is cool and dry with cyanotic nail beds.
B)   Skin is cool and moist with cyanotic nail beds.
C)   Nail beds are reddened, and the skin is moist and warm.
D)   Nail beds are reddened, and the skin is dry and warm.

Question 20

When a family member asks why her father,who is being treated for cardiogenic shock,needs parenteral feeding since he is capable of eating small amounts,the nurse replies that the parenteral feedings:

Accepted Answer

A)   Reduce the risk of constipation.
B)   Meet the patient's hypermetabolic needs.
C)   Are more convenient and less time consuming .
D)   Decrease the hazard of infection.

Exam 19: Shock