Question 1: The client exhibits a blood pressure of
(see full question) 110/68 mm Hg, pulse rate of 112
beats/min, temperature of 102°F with skin
warm and flushed. Respirations are 30
breaths/min. The nurse assesses the client
may be exhibiting the early stage of which
shock?
You selected: Septic
Correct
Explanation: In the early stage of septic shock, the blood
pressure may remain normal, the heart rate
tachycardic, the respiratory rate increased,
and fever with warm, flushed skin. The
client, in the other shocks listed, usually
present with different signs such as a
normal body temperature, hypotension with
either tachycardia or bradycardia, skin that
is cool and clammy, and respiratory
distress. (less)
Question 2: The nurse is caring for a motor vehicle
(see full question) accident client who is unresponsive on
arrival to the emergency department. The
client has numerous fractures, internal
abdominal injuries, and large lacerations
on the head and torso. The family arrives
and seeks update on the client’s condition.
A family member asks, “What causes the
body to go into shock?”Given the client’s
condition, which statement is most correct?
You selected: “The client is in shock because the blood
volume has decreased in the system.”
Correct
Explanation: Shock is a life-threatening condition that
occurs when arterial blood flow and oxygen
, delivery to tissues and cells are
inadequate. Hypovolemic shock, where the
volume of extracellular fluid is significantly
diminished due to the loss of or reduced
blood or plasma, frequently occurs with
accidents. (less)
Question 3: Which stage of shock would encompass
(see full question) mechanical ventilation, altered level of
consciousness, and profound acidosis?
You selected: Irreversible
Correct
Explanation: The irreversible stage encompasses use of
mechanical ventilation, altered
consciousness, and profound acidosis. The
compensatory stage encompasses
decreased urinary output, confusion, and
respiratory alkalosis. The progressive
stage involves metabolic acidosis, lethargy,
rapid, shallow respirations. There is not a
stage of shock called the precompensatory
stage. (less)
Question 4: A 74-year-old male client who is suffering a
(see full question) myocardial infarction is transported to the
ED by ambulance. This client is at greatest
risk for developing which type of shock?
You selected: Cardiogenic shock
Correct
Explanation: Cardiogenic shock is caused by decreased
force of ventricular contraction. Both
myocardial infarction and cardiac
dysrhythmia may cause cardiogenic shock.
, This type of shock is characterized by an
impaired filling of heart with blood due to
mechanical impediment, such as cardiac
tamponade, dissecting aneurysm, or
tension pneumothorax. This type of shock
is caused by the enlargement of the
vascular compartment and redistribution of
intravascular fluid from arterial circulation
to venous or capillary areas. Hypovolemic
shock is caused by decreased blood
volume with decreased filling of the
circulatory system. Typical examples are
hemorrhage, extreme dieresis, and third-
spacing. (less)
Question 5: Elevating the patient’s legs slightly to
(see full question) improve cerebral circulation is
contraindicated in which of the following
disease processes?
You selected: Head injury
Correct
Explanation: An alternative to the “Trendelenburg”
position is to elevate the patient’s legs
slightly to improve cerebral circulation and
promote venous return to the heart, but this
position is contraindicated for patients with
head injuries. (less)
Question 6: When a patient is in the compensatory
(see full question) stage of shock, which of the following
symptoms occurs?
Correct response: Tachycardia
Explanation: The compensatory stage of shock
, encompasses a normal BP, tachycardia,
decreased urinary output, confusion, and
respiratory alkalosis.
Question 7: The nurse taking care of a patient
(see full question) evidencing signs of shock empties the
urinary catheter drainage bag after her 12-
hour shift. The nurse notes an indicator of
renal hypoperfusion. What is the relevant
urinary output for this condition?
You selected: 300 mL
Correct
Explanation: An indicator of renal hypoperfusion is a
urinary output of less than 30 mL/hr. An
output of 300 mL in 12 hours is less than
30 mL/hr, which is indicative of oliguria.
Question 8: A client admitted with a massive
(see full question) myocardial infarction rapidly
develops cardiogenic shock. Ideally, the
physician would use the intra-aortic balloon
pump (IABP) to support the injured
myocardium. However, this client has a
history of unstableangina pectoris, aortic
insufficiency, hypertension, and diabetes
mellitus. Which condition is
a contraindication for IABP use?
Incorrect
Correct response: Aortic insufficiency
Explanation: A history of aortic insufficiency
contraindicates use of the IABP. Other
(see full question) 110/68 mm Hg, pulse rate of 112
beats/min, temperature of 102°F with skin
warm and flushed. Respirations are 30
breaths/min. The nurse assesses the client
may be exhibiting the early stage of which
shock?
You selected: Septic
Correct
Explanation: In the early stage of septic shock, the blood
pressure may remain normal, the heart rate
tachycardic, the respiratory rate increased,
and fever with warm, flushed skin. The
client, in the other shocks listed, usually
present with different signs such as a
normal body temperature, hypotension with
either tachycardia or bradycardia, skin that
is cool and clammy, and respiratory
distress. (less)
Question 2: The nurse is caring for a motor vehicle
(see full question) accident client who is unresponsive on
arrival to the emergency department. The
client has numerous fractures, internal
abdominal injuries, and large lacerations
on the head and torso. The family arrives
and seeks update on the client’s condition.
A family member asks, “What causes the
body to go into shock?”Given the client’s
condition, which statement is most correct?
You selected: “The client is in shock because the blood
volume has decreased in the system.”
Correct
Explanation: Shock is a life-threatening condition that
occurs when arterial blood flow and oxygen
, delivery to tissues and cells are
inadequate. Hypovolemic shock, where the
volume of extracellular fluid is significantly
diminished due to the loss of or reduced
blood or plasma, frequently occurs with
accidents. (less)
Question 3: Which stage of shock would encompass
(see full question) mechanical ventilation, altered level of
consciousness, and profound acidosis?
You selected: Irreversible
Correct
Explanation: The irreversible stage encompasses use of
mechanical ventilation, altered
consciousness, and profound acidosis. The
compensatory stage encompasses
decreased urinary output, confusion, and
respiratory alkalosis. The progressive
stage involves metabolic acidosis, lethargy,
rapid, shallow respirations. There is not a
stage of shock called the precompensatory
stage. (less)
Question 4: A 74-year-old male client who is suffering a
(see full question) myocardial infarction is transported to the
ED by ambulance. This client is at greatest
risk for developing which type of shock?
You selected: Cardiogenic shock
Correct
Explanation: Cardiogenic shock is caused by decreased
force of ventricular contraction. Both
myocardial infarction and cardiac
dysrhythmia may cause cardiogenic shock.
, This type of shock is characterized by an
impaired filling of heart with blood due to
mechanical impediment, such as cardiac
tamponade, dissecting aneurysm, or
tension pneumothorax. This type of shock
is caused by the enlargement of the
vascular compartment and redistribution of
intravascular fluid from arterial circulation
to venous or capillary areas. Hypovolemic
shock is caused by decreased blood
volume with decreased filling of the
circulatory system. Typical examples are
hemorrhage, extreme dieresis, and third-
spacing. (less)
Question 5: Elevating the patient’s legs slightly to
(see full question) improve cerebral circulation is
contraindicated in which of the following
disease processes?
You selected: Head injury
Correct
Explanation: An alternative to the “Trendelenburg”
position is to elevate the patient’s legs
slightly to improve cerebral circulation and
promote venous return to the heart, but this
position is contraindicated for patients with
head injuries. (less)
Question 6: When a patient is in the compensatory
(see full question) stage of shock, which of the following
symptoms occurs?
Correct response: Tachycardia
Explanation: The compensatory stage of shock
, encompasses a normal BP, tachycardia,
decreased urinary output, confusion, and
respiratory alkalosis.
Question 7: The nurse taking care of a patient
(see full question) evidencing signs of shock empties the
urinary catheter drainage bag after her 12-
hour shift. The nurse notes an indicator of
renal hypoperfusion. What is the relevant
urinary output for this condition?
You selected: 300 mL
Correct
Explanation: An indicator of renal hypoperfusion is a
urinary output of less than 30 mL/hr. An
output of 300 mL in 12 hours is less than
30 mL/hr, which is indicative of oliguria.
Question 8: A client admitted with a massive
(see full question) myocardial infarction rapidly
develops cardiogenic shock. Ideally, the
physician would use the intra-aortic balloon
pump (IABP) to support the injured
myocardium. However, this client has a
history of unstableangina pectoris, aortic
insufficiency, hypertension, and diabetes
mellitus. Which condition is
a contraindication for IABP use?
Incorrect
Correct response: Aortic insufficiency
Explanation: A history of aortic insufficiency
contraindicates use of the IABP. Other
