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Neurogenic shock is classified as an imbalance of sympathetic and parasympathetic stimulation. As parasympathetic activity increases, what assessment finding should the nurse anticipate?
Bradycardia
A client who was admitted with electrical burns 24 hours ago is experiencing ventricular tachycardia. How should the nurse interpret this finding?
The heart rhythm is directly related to the electrical burn
The nurse in the ICU is admitting a 57-year-old with a diagnosis of possible septic shock. The nurse's assessment reveals that the client has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?
The client is in the compensatory stage of shock
A client with a known peanut allergy suddenly develops wheezing, hypotension, and urticaria after eating a dessert. Which medication should the nurse administer first?
Intramuscular epinephrine
A client is brought to the emergency department after being submerged in cold water for 15 minutes following a boating accident. The client's body temperature is 89°F (31.7°C). Which warming method would be most effective?
Application of warmed towels to the neck, groin, chest, and axillae
The client was discharged from the hospital four days ago and has been receiving home health nursing care. Today when the nurse visits, the nurse suspects the client had a stroke and calls the ambulance to get the client to the emergency department. What assessment finding led to the nurse's suspicion of a stroke?
Asymmetry of the face
The nurse cares for a client who had surgery 16 hours ago. The nurse is called to the surgeon's office. What assessment finding should the nurse report immediately?
Constant pain and abdominal distention
A client with cardiogenic shock is receiving dobutamine to improve myocardial contractility. Which complication should the nurse carefully monitor for?
Tachyarrhythmias
A client is admitted to the emergency department with signs of hypovolemic shock following a severe gastrointestinal bleed. Which intervention should the nurse prioritize?
Provide supplemental oxygen via a non-rebreather mask
A client arrives in the emergency department with a suspected opioid overdose and pinpoint pupils. What is the priority nursing action?
Initiate IV access and prepare naloxone
The nurse prepares a client with cirrhosis and an intestinal obstruction for surgery in 2 hours. The nurse reviews the client's laboratory results and notes the prothrombin time is 13 seconds, the international normalized ratio is 1.4, and partial thromboplastin time is 47 sec. What is the nurse's priority action?
Contact the healthcare provider
The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries suffered in a motor vehicle accident. The nurse anticipates that the client will be promptly ordered the administration of a crystalloid IV solution to restore intravascular volume. In addition to normal saline, which crystalloid fluid is commonly used to treat hypovolemic shock?
Lactated Ringer's
A client with distributive shock is receiving norepinephrine to maintain blood pressure. What complication of this drug could require physician notification?
Peripheral ischemia
A client in the compensatory stage of shock presents with cool, pale skin, decreased urine output, and a respiratory rate of 28 breaths per minute. Which intervention should the nurse prioritize?
Initiating IV fluids and therapy with oxygen
A client with a known history of substance use disorder is brought to the emergency department after being found unconscious with an empty bottle of tricyclic antidepressants. What is the nurse's first action?
Provide airway support and cardiac monitoring
When assessing a client with a pneumothorax the nurse finds that the trachea has shifted to the uninvolved side. What additional assessment finding would the nurse assess for?
Decreased chest expansion on involved side
A client in shock is receiving dopamine in addition to IV fluids. Which principle will guide the nurse's care planning during the administration of this vasoactive drug? Select all that apply.
The drug should be administered through a central venous line
The drug dose should be tapered down once vital signs improve
The infusion rate should be titrated for a mean arterial pressure (MAP) of 65
A client with suspected septic shock has a respiratory rate of 28 breaths per minute, altered mentation, and blood pressure of 78/43 mm Hg (MAP 55). Which action should the nurse take first?
Begin rapid administration of 30 mL/kg crystalloid for hypotension
A client with septic shock is receiving aggressive fluid resuscitation. Despite this, the client's mean arterial pressure (MAP) remains below 65 mmHg. Which action should the nurse take next?
Administer a vasopressor such as norepinephrine
A client is brought to the emergency department by their partner, who reports working near a faulty hot water heater. The client reports confusion and headache. What action should the nurse take first?
Provide oxygen and prepare for hyperbaric oxygen therapy
A frail older adult client is scheduled for a surgical procedure. How will the surgical team ensure the client does not experience complications from hypothermia during surgery? Select all that apply
Perform close monitoring of the client's temperature
Administer intravenous fluids that are warmed
Have a thermal warming blanket on hand
A nurse in the ICU receives report from the nurse in the ED about a new client being admitted who sustained a neck injury while diving into a lake. The ED nurse reports that blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that client is probably experiencing?
Neurogenic shock
A client in the compensatory stage of shock is experiencing a narrowing pulse pressure, cool and pale skin, and decreased urine output. The nurse recognizes these findings as consistent with which physiologic response?
Sympathetic nervous system response resulting in shunting of blood to vital organs
A young adult client arrives in the emergency department and reports being sexually assaulted. The client is visibly distressed. What is the nursing action?
Provide a safe environment and assess immediate needs
In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for shock in which circumstance?
Fluid volume circulating in the blood vessels decreases