NU304 EXAM /QUESTIONS & 100% CORRECT ANSWERS (
verified ) LATEST UPDATE |GRADE A+.
Medical management of neuro shock? - CORRECT ANSWERS-restoring sympathetic
tone, either thru stabilization of spinal cord injury or in the instance of spinal anesthesia
by positioning the pt properly, vasopressors
NI for neuro shock? - CORRECT ANSWERS--elevate and maintain HOB at least 30
degrees to prevent neuro shock when a pt has spinal anesthesia or epidural
-carefully immobilizing the pt to prevent damage to spinal cord
-VTE prophylaxis by SCDs and antithrombotic agents(lovenox) (assess daily for any
lower extremity pain, redness, tendernesss, warmth)
-monitor pt for internal bleeding that could lead to hypovolemic shock
What is anaphylactic shock? - CORRECT ANSWERS-an extreme, often life-threatening
allergic reaction to an antigen to which the body has become hypersensitive.
What are the three defining characteristics of anaphylactic shock? - CORRECT
ANSWERS--acute onset of symptoms
-presence of 2 or more symptoms that include resp compromise, reduced BP, GI
distress, and skin or mucosal tissue irritation
-CV compromise form mins to hrs after exposure to the antigen
What does parasympathetic stimulation cause? - CORRECT ANSWERS-vascular
smooth muscle to relax or dilate
Is blood volume adequate in neurogenic shock? Why or why not? - CORRECT
ANSWERS-adequate, bc the vasculature is dilated; the blood volume is displaced,
producing a hypotensive state- a decrease in the pts systemic vascular resistance and
bradycardia
What can cause neuro shock? - CORRECT ANSWERS-spinal cord injury, spinal
anesthesia, other nervous system damage, depressant action of meds or from lack of
glucose (insulin reaction)
What are some manifestations of neuro shock? - CORRECT ANSWERS-Warm, dry
skin, hypotension with bradycardia, syncope
How long does anaphylatic s/s take to present? - CORRECT ANSWERS-within 2-30
mins of exposure to antigen, occasionally several hrs after
Pt s/s of anaphylaxis - CORRECT ANSWERS--mild= headache, lightheadedness, n/v,
pruitis, generalized flushing, dyspnea, bronchospasm, cardiac arrhythmias, hypotension
-severe= rapid hypotension, decreased LOC, resp distress, cardiac arrest
,medical management of anaphylactic shock? - CORRECT ANSWERS--Remove
causative antigen
-Provide Fluids aggressively
-Provide Medication (epi)
-Support cardiovascular and respiratory function (CPR)
NI for anaphylactic shock - CORRECT ANSWERS--education/ assessment of allergy
response
-removal of antigen if possible
-CPR
When admin new meds to a pt, the nurse observes for allergic reactions especially
when administering what meds? - CORRECT ANSWERS-antibiotics, BB, ACEs/ ARBs,
ASA, NSAIDs
What is MODS? - CORRECT ANSWERS-*multiple organ dysfunction syndrome*
-an altered organ function in acutely ill pts that requires medical intervention to support
continued organ function- it is another phase in the progression of shock states
Dysfunction of one organ system is associated with BLANK percent mortality, and if
more than four organs fail, the mortality is at least BLANK percent. - CORRECT
ANSWERS-20%= 1 organ
60%= more than four organs
Where does organ failure typically occur first? - CORRECT ANSWERS-lungs and CV
instability as well as failure of the hepatic, GI, renal, immunologic, and central nervous
sytems
Medical management of MODS? - CORRECT ANSWERS--prevention
-early detection
-control initiating event
-promote adequate organ perfusion
-provide nutritional support
-wounds- inc risk for MODS
NI for MODS? - CORRECT ANSWERS--open communication with pt wishes
-edu for pts who survive MODS regarding rehab goals and expectations
Risk factors for septic shock? - CORRECT ANSWERS-Immunosuppression
Extremes of age (<1 yr and >65 yrs)
Malnourishment
Chronic illness
Invasive procedures
Emergent and/or multiple surgeries
, Risk factors of neurogenic shock - CORRECT ANSWERS--Spinal cord injury
-Spinal anesthesia
-Depressant action of medication
risk factors of anaphylactic shock - CORRECT ANSWERS--history of med sensitivity
What is shock? - CORRECT ANSWERS-inadequate tissue perfusion
What is the patho of shock? - CORRECT ANSWERS-cellular changes, vascular
response, and changes in BP
What is the sequence of regulatory mechanisms in shock? - CORRECT ANSWERS-
FIGURE 11-2 in textbook
What are the three stages of shock? - CORRECT ANSWERS-Compensatory
Progressive
Irreversible
What is occurring in the compensatory stage of shock? - CORRECT ANSWERS--
Inadequate perfusion
-Increased respirations
-Anxiety
-Confusion
Clinical manifestations of compensatory stage of shock? - CORRECT ANSWERS-
*Fight of Flight Response*
-Normal BP
-HR >100, adequate CO
-RR > or equal to 22
-Skin will be cold, clammy, shorter than 3.5 second cap refill
-decreased UOP
-agitated and confused
-respiratory alkalosis
What is the medical management for compensatory stage of shock? - CORRECT
ANSWERS--treat underlying cause
-replace fluids
-supplemental O2, decrease pt anxiety
-maintain BP and tissue perfusion
*early intervention is key to improving pt prognosis*
Nursing interventions for compensatory stage of shock? - CORRECT ANSWERS--
Complete frequent assessments of your pt (risk for shock, recognize subtle clinical
signs of this stage prior to BP dropping)
-Monitor tissue perfusion (LOC, vitals, UOP, skin- cap refill & mottling, RR, lab values)
verified ) LATEST UPDATE |GRADE A+.
Medical management of neuro shock? - CORRECT ANSWERS-restoring sympathetic
tone, either thru stabilization of spinal cord injury or in the instance of spinal anesthesia
by positioning the pt properly, vasopressors
NI for neuro shock? - CORRECT ANSWERS--elevate and maintain HOB at least 30
degrees to prevent neuro shock when a pt has spinal anesthesia or epidural
-carefully immobilizing the pt to prevent damage to spinal cord
-VTE prophylaxis by SCDs and antithrombotic agents(lovenox) (assess daily for any
lower extremity pain, redness, tendernesss, warmth)
-monitor pt for internal bleeding that could lead to hypovolemic shock
What is anaphylactic shock? - CORRECT ANSWERS-an extreme, often life-threatening
allergic reaction to an antigen to which the body has become hypersensitive.
What are the three defining characteristics of anaphylactic shock? - CORRECT
ANSWERS--acute onset of symptoms
-presence of 2 or more symptoms that include resp compromise, reduced BP, GI
distress, and skin or mucosal tissue irritation
-CV compromise form mins to hrs after exposure to the antigen
What does parasympathetic stimulation cause? - CORRECT ANSWERS-vascular
smooth muscle to relax or dilate
Is blood volume adequate in neurogenic shock? Why or why not? - CORRECT
ANSWERS-adequate, bc the vasculature is dilated; the blood volume is displaced,
producing a hypotensive state- a decrease in the pts systemic vascular resistance and
bradycardia
What can cause neuro shock? - CORRECT ANSWERS-spinal cord injury, spinal
anesthesia, other nervous system damage, depressant action of meds or from lack of
glucose (insulin reaction)
What are some manifestations of neuro shock? - CORRECT ANSWERS-Warm, dry
skin, hypotension with bradycardia, syncope
How long does anaphylatic s/s take to present? - CORRECT ANSWERS-within 2-30
mins of exposure to antigen, occasionally several hrs after
Pt s/s of anaphylaxis - CORRECT ANSWERS--mild= headache, lightheadedness, n/v,
pruitis, generalized flushing, dyspnea, bronchospasm, cardiac arrhythmias, hypotension
-severe= rapid hypotension, decreased LOC, resp distress, cardiac arrest
,medical management of anaphylactic shock? - CORRECT ANSWERS--Remove
causative antigen
-Provide Fluids aggressively
-Provide Medication (epi)
-Support cardiovascular and respiratory function (CPR)
NI for anaphylactic shock - CORRECT ANSWERS--education/ assessment of allergy
response
-removal of antigen if possible
-CPR
When admin new meds to a pt, the nurse observes for allergic reactions especially
when administering what meds? - CORRECT ANSWERS-antibiotics, BB, ACEs/ ARBs,
ASA, NSAIDs
What is MODS? - CORRECT ANSWERS-*multiple organ dysfunction syndrome*
-an altered organ function in acutely ill pts that requires medical intervention to support
continued organ function- it is another phase in the progression of shock states
Dysfunction of one organ system is associated with BLANK percent mortality, and if
more than four organs fail, the mortality is at least BLANK percent. - CORRECT
ANSWERS-20%= 1 organ
60%= more than four organs
Where does organ failure typically occur first? - CORRECT ANSWERS-lungs and CV
instability as well as failure of the hepatic, GI, renal, immunologic, and central nervous
sytems
Medical management of MODS? - CORRECT ANSWERS--prevention
-early detection
-control initiating event
-promote adequate organ perfusion
-provide nutritional support
-wounds- inc risk for MODS
NI for MODS? - CORRECT ANSWERS--open communication with pt wishes
-edu for pts who survive MODS regarding rehab goals and expectations
Risk factors for septic shock? - CORRECT ANSWERS-Immunosuppression
Extremes of age (<1 yr and >65 yrs)
Malnourishment
Chronic illness
Invasive procedures
Emergent and/or multiple surgeries
, Risk factors of neurogenic shock - CORRECT ANSWERS--Spinal cord injury
-Spinal anesthesia
-Depressant action of medication
risk factors of anaphylactic shock - CORRECT ANSWERS--history of med sensitivity
What is shock? - CORRECT ANSWERS-inadequate tissue perfusion
What is the patho of shock? - CORRECT ANSWERS-cellular changes, vascular
response, and changes in BP
What is the sequence of regulatory mechanisms in shock? - CORRECT ANSWERS-
FIGURE 11-2 in textbook
What are the three stages of shock? - CORRECT ANSWERS-Compensatory
Progressive
Irreversible
What is occurring in the compensatory stage of shock? - CORRECT ANSWERS--
Inadequate perfusion
-Increased respirations
-Anxiety
-Confusion
Clinical manifestations of compensatory stage of shock? - CORRECT ANSWERS-
*Fight of Flight Response*
-Normal BP
-HR >100, adequate CO
-RR > or equal to 22
-Skin will be cold, clammy, shorter than 3.5 second cap refill
-decreased UOP
-agitated and confused
-respiratory alkalosis
What is the medical management for compensatory stage of shock? - CORRECT
ANSWERS--treat underlying cause
-replace fluids
-supplemental O2, decrease pt anxiety
-maintain BP and tissue perfusion
*early intervention is key to improving pt prognosis*
Nursing interventions for compensatory stage of shock? - CORRECT ANSWERS--
Complete frequent assessments of your pt (risk for shock, recognize subtle clinical
signs of this stage prior to BP dropping)
-Monitor tissue perfusion (LOC, vitals, UOP, skin- cap refill & mottling, RR, lab values)
