Shock/Stages of Shock
Vomiting, pancreatitis, bowel obstruction, diabetes insipidus, severe burns.
What are causes of Hypovolemic shock
A patient with partial-thickness burns is grimacing and moaning. What is the best pharmacological intervention?
What is administer IV opioids such as morphine for pain relief?
A patient with TBI is increasingly drowsy and has a widening pulse pressure. What complication is likely developing?
What is increased intracranial pressure (ICP)?
A woman’s last menstrual period began on October 1st. What is her estimated due date?
What is July 8th?
A postpartum client receiving magnesium sulfate becomes lethargic, her respiratory rate drops to 10/min, and her reflexes are absent.
What is magnesium toxicity?
A 3-day postpartum client states, “I cry for no reason. I love my baby, but I just feel overwhelmed.” The nurse recognizes this as:
What is postpartum blues?
Stage of shock characterized by normal B/P, tachycardia, tachypnea, and peripheral vasoconstriction
Compensatory stage of shock
A burn patient arrives in the ER. The burn area is extensive, and the patient is confused and hypotensive. What are the general priority nursing interventions?
What is initiate IV fluid resuscitation with lactated Ringer’s and maintain airway?
A patient in the ICU after a motorcycle crash has a Glasgow Coma Scale score of 5, does not respond to verbal stimuli, and has abnormal posturing. What type of brain injury does he have?
What is a severe traumatic brain injury?
A pregnant client is found to be Rh-negative and her partner is Rh-positive. She has no anti-D antibodies.
What is administer Rho(D) immune globulin at 28 weeks and again postpartum if the baby is Rh-positive?
A client in preterm labor at 28 weeks is given IV magnesium sulfate. The nurse knows this is also used for:
What is neuroprotection of the fetus and stopping uterine contractions?
Which of the following should the nurse teach the family of a client experiencing postpartum blues?
What is symptoms typically resolve in 10–14 days with support and rest?
This is the final and most severe stage of shock, in which organ damage is so profound that recovery is unlikely, even with aggressive treatment.
What is the Refractory Stage of shock?
A patient is 8 hours post-burn injury and has crackles in the lungs, peripheral edema, and jugular vein distention. What is the nurse's best response?
What is slow the IV fluid rate and notify the provider of signs of fluid overload?
A TBI patient’s vitals are: BP 190/80, HR 48, RR 10. Pupils are dilated and non-reactive. What is this a sign of?
What is Cushing’s triad indicating brain herniation?
A patient in her third trimester complains of sudden severe abdominal pain and bright red bleeding. The uterus is rigid and tender.
What is suspect placental abruption and prepare for emergency delivery?
A nurse finds a postpartum client drowsy with shallow breathing and non-palpable patellar reflexes. The magnesium level is 9.5 mEq/L.
What is magnesium toxicity; stop the infusion and give calcium gluconate stat?
A client who had a miscarriage is crying uncontrollably. Which action is most therapeutic?
What is sit quietly with her and allow her to express her emotions freely?
A 65-year-old male with a recent myocardial infarction reports chest pain, is cool and clammy, has a BP of 78/60 mmHg, crackles in the lungs, and signs of altered mental status.
What is cardiogenic shock?
A patient with flame injuries has areas of skin that are white, dry, and leathery, with no pain or sensation in the area.
What is a full-thickness (third-degree) burn?
A patient with a TBI becomes restless and pulls at their IV lines. Vitals: HR 102, BP 170/90, RR 22. What action should the nurse take?
What is assess for increased ICP and notify the provider?
A woman at 10 weeks presents with severe nausea, vomiting, weight loss, and dehydration.
What is hyperemesis gravidarum; initiate IV fluids and electrolyte replacement?
A nurse is titrating magnesium sulfate per protocol. The therapeutic serum magnesium level for seizure prevention is:
What is 4–7 mEq/L?
A 5-day postpartum client says, “I heard God tell me to protect my baby from the devil.” What condition does this indicate?
What is postpartum psychosis?
A 72-year-old patient with a history of a urinary tract infection becomes confused and lethargic. Temperature is 103°F (39.4°C), HR is 128 bpm, BP is 82/50 mmHg, and skin is warm and flushed.
What is septic shock?
A patient with burns down to the muscle and bone presents after a high-voltage electrical accident. Skin is blackened, with exposed tissue and absent sensation.
What is a deep full-thickness (fourth-degree) burn?
A patient is restless with increased ICP. The HOB is flat, and the neck is rotated to the side. What should the nurse do?
What is elevate the HOB to 30° and keep the head midline?
A 28-week client reports painless vaginal bleeding. Fetal heart tones are stable.
What is placenta previa, and the priority is to avoid vaginal exams and prepare for possible C-section?
A nurse receives an order to increase the magnesium sulfate rate on a postpartum client who is drowsy with a respiratory rate of 11. What is the priority?
What is hold the increase, assess closely, and notify the provider—client is showing signs of toxicity?
A grieving mother asks, “Why did this happen to me?” The best response is:
What is “I don’t have all the answers, but I want to listen and support you.”