Understanding The Essentials Of Critical Care Nursing
By Perrin -Test
Bank Care of the Patient Experiencing Shock or Heart
Failure
,1) Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that
apply.)
1. A temperature of 97.6°F (36.4°C)
2. A decrease in blood pressure of 20 mm Hg when the patient sits up
3. Capillary refill time greater than 3 seconds
4. Restlessness
5. Sinus bradycardia of 55 beats per minute
Answer: 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
2. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
,cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
3. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
, Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 137
4. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
5. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
By Perrin -Test
Bank Care of the Patient Experiencing Shock or Heart
Failure
,1) Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that
apply.)
1. A temperature of 97.6°F (36.4°C)
2. A decrease in blood pressure of 20 mm Hg when the patient sits up
3. Capillary refill time greater than 3 seconds
4. Restlessness
5. Sinus bradycardia of 55 beats per minute
Answer: 2, 3, 4
Explanation: 1. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
2. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
,cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
3. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
, Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 137
4. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
to increase the heart rate (tachycardia) to circulate the blood faster to make up for the fluids
that are not present in hypovolemic shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
5. (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease the
blood to the brain by gravitational pull and will require increased peripheral resistance or
cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will increase oxygen
demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe
dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures
by peripheral shunting of blood away from the extremities and reducing the core metabolic
rate. If septic shock is present fever might be present, but it is not present in all patients with
hypovolemic shock. #5 is incorrect. Bradycardia is not present. The compensatory response is
