TEST BANK FOR MEDICAL SURGICALNURSING 7TH EDITION BY ADRIANNE DILL LINTON ALL CHAPTERS COVERED.

1. What are the four types of shock? 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 ANS: D The four large categories of shock are hypovolemic (low-circulating volume), cardiogenic (low-cardiac output), obstructive (occluded vascular pathway), and vasogenic (massive vasodilation). DIF: Cognitive Level: Knowledge REF: p. 153 OBJ: 1 TOP: Types of Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Although several life-supporting systems of the body are involved in the pathophysiologic characteristics of shock, shock itself results from failure of which system? a. Circulatory b. Endocrine c. Neurologic d. Respiratory ANS: A When the heart fails as a pump, the lack of tissue perfusion follows and deprives all the body’s cells of oxygen and the removal of wastes. DIF: Cognitive Level: Knowledge REF: p. 153 OBJ: 2 TOP: Definition of Shock KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. A nurse is assessing a patient who is in shock. What should the nurse be aware that one common sign will be, regardless of the cause of the shock? a. The skin is cool and dry with cyanotic nail beds. b. The skin is cool and moist with cyanotic nail beds. c. The nail beds are reddened, and the skin is moist and warm. d. The nail beds are reddened, and the skin is dry and warm. ANS: B Venous blood pools in the extremities of the fingers as a result of the lack of adequate perfusion of tissues, which makes the skin cool and moist from a lack of oxygen and waste exchanges. DIF: Cognitive Level: ComprehensionREF: p. 157 OBJ: 3 TOP: Common Signs of Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. What should a nurse assessing a patient in the organ-dysfunction stage of shock expect to find? a. Bounding pulse, decreased respirations, and decreased blood pressure b. Bounding pulse, shallow respirations, and significantly increased blood pressure c. Thready pulse and deep respirations with decreased blood pressure d. Thready pulse and irregular respirations with increased blood pressure ANS: C When the cause of shock is not corrected, irreversible organ damage takes place. The pulse is weak; the respirations increase in an effort to decrease the carbon dioxide level; and, with less volume being pumped, the blood pressure falls. DIF: Cognitive Level: ComprehensionREF: p. 156 OBJ: 3 TOP: Signs of Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A licensed practical/vocational nurse (LPN/LVN) is assisting in developing a nursing care plan for a patient in shock. Which patient problem should be included? a. Excess cardiac output, related to hypertension b. Excess cardiac output, related to hypotension c. Inadequate cardiac output, related to hypovolemia d. Inadequate cardiac output, related to hypertension ANS: C Decreased amount of blood is ejected from the heart because of a decreased volume of fluid in the intravascular compartment. DIF: Cognitive Level: Application REF: p. 153 OBJ: 7 TOP: Nursing Diagnosis for Patients in Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. How does the intraaortic balloon pump (IABP) assist a patient who is in cardiogenic shock to increase cardiac output? a. Provides generalized vasoconstriction. b. Inflates during the diastole phase. c. Constricts the vena cava. d. Adds hypertonic fluid to the circulating volume. ANS: B The IABP inflates during diastole (relaxation) phase and deflates during the systole (constriction) phase, which improves cardiac output. DIF: Cognitive Level: ComprehensionREF: p. 160 OBJ: 6 TOP: IABP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A nurse is explaining to a family member the pathophysiologic characteristic of distributive shock. What information should the nurse include? a. The intravascular compartment fills beyond capacity, allowing fluid to leak out, compressing vital organs. b. The circulating volume causes excessive constriction of the vessels, causing blood pooling. c. Widely fluctuating blood pressures stimulate vascular collapse, causing severe alterations in peripheral perfusion. d. Although the circulating volume is intact, excessive vascular dilation causes drastic drops in the blood pressure. ANS: D In distributive shock, blood pooling from dilated vessels drops the blood pressure without loss of circulating volume. DIF: Cognitive Level: Knowledge REF: p. 154 OBJ: 2 TOP: Distributive Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A nurse is caring for a patient who has a cervical spine injury and assesses progressive hypotension. What does this signify? a. Anaphylaxis b. Respiratory alkalosis c. Multiple organ dysfunction syndrome (MODS) d. Neurogenic shock ANS: D Gradually decreasing blood pressure in a person with a spinal injury is an indicator of neurogenic shock related to the parasympathetic stimulation, which causes generalized vasodilation. DIF: Cognitive Level: ComprehensionREF: p. 155 OBJ: 3 TOP: Implementation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. While shopping in the mall, a 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). What should be the immediate actions by the nurse? 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. ANS: C Shock treatment requires expert medical implementation. However, the nurse may provide first-line support until such help arrives. Circulatory collapse has to be monitored first; pulse, respiration, and mental status should be assessed to evaluate whether oxygen is reaching the brain. DIF: Cognitive Level: Application REF: p. 157 OBJ: 4 TOP: Emergency Aid for Shock Victim KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. A nurse is explaining the rationale behind the use of hypothermic devices to a patient’s family. When relaying information what explanation should the nurse provide when asked why this garment is used? a. To improve neurologic recovery. b. Decreases internal hemorrhage. c. Warms the patient to create less metabolic demand. d. Applies pressure during the systole phase and relax pressure during the diastole phase. ANS: A Hypothermic devices cool the body by circulating ice water while in direct contact with the patient’s skin. These devices may improve neurologic recovery after cardiac arrest of cardiac origin. DIF: Cognitive Level: ComprehensionREF: p. 160 OBJ: 6 TOP: Hypothermic devices KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. In treating a person outside of a medical facility, a 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? a. 4 b. 6 c. 14 d. 24 ANS: A Brain cells must have oxygen to live; they are very sensitive to lack of oxygen and begin to die in 4 minutes. DIF: Cognitive Level: Knowledge REF: p. 165 OBJ: 2 TOP: Brain Death without Oxygen KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The stages of shock proceed in a definite sequence. What is the correct order? a. Hypovolemic, obstructive, cardiogenic b. Cardiogenic, hypovolemic, obstructive c. Pre-shock, shock, end-organ dysfunction d. Pre-shock, end-organ dysfunction, shock ANS: C The sequence of the stages of shock are pre-shock, shock, and end-organ dysfunction. Understanding the sequence of the progression of shock allows the medical team to plan and implement the correct steps to reverse it. Hypovolemic, obstructive, and cardiogenic are types of shock. DIF: Cognitive Level: Knowledge REF: p. 155 OBJ: 1 TOP: Stages of Shock KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. Which position enhances cerebral blood flow to counteract the symptoms of neurogenic shock? a. Fowler b. Trendelenburg c. Gravity neutral d. Side lying ANS: B The Trendelenburg position, with the patient’s head down, allows gravity to pull blood to the cerebrum. All other positions are ineffective for improving cerebral perfusion. DIF: Cognitive Level: Knowledge REF: p. 164 OBJ: 5 TOP: Positions to Counteract Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A nurse is administering heparin, subcutaneous twice daily, to a patient in cardiogenic shock. What is the expected action of this drug? a. Inotropic to improve cardiac contractibility b. Anticoagulant to prevent blood clots c. Antidysrhythmic to restore normal cardiac contractibility d. Vasopressor to increase blood pressure ANS: B Cardiogenic shock may produce clots because of blood stasis, and the heparin will delay clot formation. DIF: Cognitive Level: Knowledge REF: p. 163 OBJ: 5 | 6 TOP: Heparin for Anticoagulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. One of the most important assessments that a nurse makes is to check urine output. Which value objectively validates minimal acceptable renal perfusion for the average-size person? a. 0.5 mL/kg/hr b. 0.5 mL/lb/hr c. 1 mL/lb/hr d. 0.2 mL/kg/hr ANS: A When the kidneys produce at least 0.5 mL/kg/hr of urine, the indication is that the vital organs are also being perfused. DIF: Cognitive Level: Knowledge REF: p. 161 OBJ: 5 TOP: Urine Output As Measure of Tissue Perfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. A patient is receiving norepinephrine as a first line treatment for shock in order to increase vascular resistance. Which type of shock is the patient being treated for? a. Septic b. Cardiogenic c. Anaphylactic d. Neurogenic ANS: A Norepinephrine is used as a first line treatment for septic shock in order to increase vascular resistance.