Anaphylactic/Septic Shock
A patient receiving IV antibiotics suddenly develops wheezing, lip swelling, and blood pressure of 78/42 mmHg. What is the first action the nurse should take?
Correct Answer: stop the infusion and maintain the airway
Rationale: These are signs of anaphylaxis and that requires immediate discontinuation of the allergen and airway support.
Before starting vasopressors, this is the PRIORITY intervention for hypovolemic shock (“if the tank is empty, you have to fill it”)
Correct Answer: IV Fluid Resuscitation
Rationale: Fluid resuscitation helps increase circulating volume, perfusion, and urine output before any vasopressor can be effective
This type of shock is known as a “failed pump” and causes systemic hypoperfusion
Correct Answer: Cardiogenic Shock
Rationale: In cardiogenic shock the heart has lost the ability to pump enough blood causing decreased cardiac output.
This vital-sign abnormality is the most distinguishing feature of neurogenic shock compared to other shock types.
Correct Answer: bradycardia
Rationale: Neurogenic shock is a loss of sympathetic tone, therefore the body is unable to turn on its “fight or flight mode” and increase the heart rate.
A nurse is assessing a client with suspected aortic dissection. Which of the following findings should the nurse expect?
Correct answer: Sudden onset of “tearing,” “ripping,” and “stabbing” pain
Rationale: Aortic dissection is characterized by sudden onset of “tearing,” “ripping,” and “stabbing” abdominal or back pain.
After administering 0.3 mg IM epinephrine to a client with anaphylaxis, this finding indicates the medication is working effectively.
Correct Answer: improved blood pressure and easier breathing
Rationale: Epinephrine improves airway patency and raises blood pressure through bronchodilation and vasoconstriction.
This assessment finding appears early in hypovolemic shock as the sympathetic nervous system tries to maintain perfusion to vital organs
Correct Answer: Tachycardia and Cool, Clammy Skin
Rationale: Early hypovolemic shock triggers SNS activation which causes tachycardia to maintain cardiac output and cool skin as blood is shunted away from skin and extremities and sent to vital organs.
What are the top priority interventions a nurse should take when caring for a patient experiencing cardiogenic shock?
Correct Answer: Oxygenation, vital signs (MAP), cardiac rhythm, urine output(report if less than 20mL/hr), IV Fluids
Rationale: Oxygenation status is going to be #1 priority due to ABCs, vital signs and MAP which tells us if the patient is being properly perfused and can be a big sign of cardiogenic shock, urine output should be reported if less than 20mL/hr as this is also a key sign which tells us if there is organ failure.
Neurogenic shock most commonly occurs after injury to this body system
Correct Answer: spinal cord
Rationale: Spinal cord injuries cause neurogenic shock by blocking the spinal cords signals damaging the sympathetic nervous system.
A nurse is assessing a client with suspected abdominal aortic aneurysm (AAA). Which finding requires immediate intervention?
Correct answer: Palpation of the abdominal mass
Rationale: Pulsating abdominal mass should not be palpated because they can cause a rupture
Septic shock is a subcategory of this type of shock because it decreases SVR and perfusion.
Correct Answer: Distributive shock
Rationale: Distributive shock is when the “pipes are too wide” which causes systemic vasodilation and leaky capillaries. This is common in septic shock because toxins trigger a massive inflammatory response which causes vasodilation and a drop in SVR.
This is a severe complication of septic shock where the client presents with micro-clotting, bleeding from multiple sites, and petechiae.
Correct Answer: Disseminated Intravascular Coagulation (DIC)
Rationale: Due to untreated infection from septic shock, simultaneous clotting and bleeding occur. The clotting factors are depleted systemically and cause severe bleedings in various areas of the body.