Chapter 11:Shock, Sepsis, and Multi Organ Dysfunction
The nurse in intensive care unit is admitting a 57-year-old client 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 which preliminary conclusion?
A. The client is in the compensatory stage of shock.
B. The client is in the progressive stage of shock.
C. The client will stabilize and be released by tomorrow.
D. The client is in the irreversible stage of shock.
ANS: A
Rationale: In the compensatory stage of shock, the blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. Clients display the often-described "fight or flight" response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the skin is cool and clammy, and bowel sounds are hypoactive. In progressive shock, the blood pressure drops. In septic shock, the client's chance of survival is low and he will certainly not be released within 24 hours. If the client were in the irreversible stage of shock, his blood pressure would be very low and his organs would be failing.
A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client?
A. Chest pain
B. Bleeding at the implantation site
C. Malignant hyperthermia
D. Bradycardia
ANS: B
Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.
Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
A. The symptoms indicate angina and should be treated as such.
B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology.
C. The symptoms indicate an acute coronary episode and should be treated as such.
D. Treatment should be determined pending the results of an exercise stress test.
ANS: C
Rationale: Angina and MI have similar symptoms and are considered the same process but are on different points along a continuum. That the client's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale, cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.
A client with a history of rheumatic heart disease knows that the client is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which drug?
A. Enoxaparin
B. Metoprolol
C. Azathioprine
D. Amoxicillin
ANS: D
Rationale: Although rare, bacterial endocarditis may be life threatening. A key strategy is primary prevention in high-risk clients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic.
The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element?
A. A spontaneous separation of dead tissue from the viable tissue
B. Removal of eschar until the point of pain and bleeding occurs
C. Shaving of burned skin layers until bleeding, viable tissue is revealed
D. Early closure of the wound
ANS: B
Rationale: Mechanical débridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement.
The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock?
A. Elevated systolic blood pressure
B. Elevated mean arterial pressure (MAP)
C. Shallow, rapid respirations
D. Bradycardia
ANS: C
Rationale: A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock, and MAP is less than 65 mm Hg. Bradycardia occurs in neurogenic shock; other states of shock have tachycardia as a symptom. Infection can lead to septic shock.
The nurse is caring for a client who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurse's assessment?
A. Assessing the client's mobility
B. Facilitating transthoracic echocardiography
C. Vigilant monitoring of the client's ECG
D. Close monitoring of the client's peripheral perfusion
ANS: C
Rationale: After a permanent electronic device (pacemaker or ICD) is inserted, the client's heart rate and rhythm are monitored by ECG. This is a priority over peripheral circulation and mobility because the consequences of abnormalities are more serious. Echocardiography is not indicated.
A client presents to the ED reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
A. Begin ECG monitoring.
B. Obtain information about family history of heart disease.
C. Auscultate lung fields.
D. Determine if the client smokes.
ANS: A
Rationale: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the client smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
A client with pericarditis has just been admitted to the critical care unit. The nurse planning the client's care should prioritize which nursing diagnosis?
A. Anxiety related to pericarditis
B. Acute pain related to pericarditis
C. Ineffective tissue perfusion related to pericarditis
D. Ineffective breathing pattern related to pericarditis
ANS: B
Rationale: The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.
A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
A. Activity intolerance
B. Anxiety
C. Ineffective coping
D. Acute pain
ANS: D
Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn client has been described as one of the most severe types of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the client's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.
The acute care nurse is providing care for an adult client who is in hypovolemic shock. The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this health problem. What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock?
A. Increased hunger
B. Decreased thirst
C. Decreased urinary output
D. Increased capillary perfusion
ANS: C
Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to further retain water in an effort to raise blood volume and blood pressure. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs.
The nurse and the other members of the team are caring for a client who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. The nurse should anticipate the administration of what medication?
A. Epinephrine 1 mg IV push
B. Lidocaine 100 mg IV push
C. Amiodarone 300 mg IV push
D. Sodium bicarbonate 1 amp IV push
ANS: A
Rationale: Epinephrine should be given as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and lidocaine are given if ventricular dysrhythmia persists.
The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:
A. drug therapy and smoking cessation.
B. diet and drug therapy.
C. diet therapy only.
D. diet therapy and smoking cessation.
ANS: D
Rationale: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostic findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.
A client newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. Which valvular disorder would the nurse anticipate being diagnosed in this client?
A. Aortic regurgitation
B. Mitral stenosis
C. Mitral valve prolapse
D. Aortic stenosis
ANS: B
Rationale: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Clients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Clients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea, and repeated respiratory infections. Pulmonary venous hypertension is not typically caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.
A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?
A. Perform mechanical débridement to remove the exudate and prevent further infection.
B. Inform the primary care provider promptly because the graft may need to be removed.
C. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing.
D. Document this finding as an expected phase of graft healing.
ANS: B
Rationale: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem, and the nurse would not independently perform débridement.
The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs?
A. The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate
B. The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity
C. The release of catecholamines that creates an increase in metabolic rate and caloric requirements
D. The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea
ANS: C
Rationale: Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.
The nurse is planning discharge teaching for a client with a newly inserted permanent pacemaker. What is the priority teaching point for this client?
A. Start lifting the arm above the shoulder right away to prevent chest wall adhesion.
B. Avoid cooking with a microwave oven.
C. Avoid exposure to strong electromagnetic fields
D. Avoid walking through store and library antitheft devices.
ANS: C
Rationale: High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows clients to safely use most household electronic appliances and devices (e.g., microwave ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker. Antitheft alarms may be triggered so clients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function.
The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs?
A. The client experiences chest pain, palpitations, or dyspnea.
B. The client experiences a noticeable increase in heart rate during activity.
C. The client's oxygen saturation level drops below 96%.
D. The client's respiratory rate exceeds 30 breaths/min.
ANS: A
Rationale: Any activity or exercise that causes dyspnea and chest pain should be stopped in the client with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most clients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.
A client who has undergone valve replacement surgery is being prepared for discharge home. Because the client will be discharged with a prescription for warfarin, the nurse would educate the client about the need to take which action?
A. Undergo regular testing of the International Normalized Ratio (INR).
B. Sleep in a semi-Fowler position for the first 6 to 8 weeks to prevent emboli.
C. Avoid foods that contain vitamin K.
D. Take enteric-coated acetylsalicylic acid (ASA) on a daily basis.
ANS: A
Rationale: Clients who take warfarin after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.
A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?
A. Confusion
B. High fever
C. Decreased blood pressure
D. Sudden agitation
ANS: C
Rationale: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.
A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client? Select all that apply.
A. Hypovolemia
B. Difficulty breathing
C. Cardiovascular overload
D. Pulmonary edema
E. Hypoglycemia
ANS: B, C, D
Rationale: Fluid replacement complications can occur, often when large volumes are given rapidly. Therefore, the nurse monitors the client closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.
A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and diltiazem are given. The nurse caring for the client understands that the treatment has what main goal?
A. Decrease SA node conduction.
B. Control ventricular heart rate.
C. Improve oxygenation.
D. Maintain anticoagulation.
ANS: B
Rationale: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.
A nurse educator is conducting an inservice for nursing students about how tobacco use impacts coronary artery disease (CAD)? What are the primary ways that tobacco use impacts CAD? Select all that apply.
A. Decreases the supply of oxygen to the myocardium
B. Increases platelet adhesion
C. Raises the heart rate and blood pressure
D. Causes the coronary arteries to dilate
E. Increases the blood carbon monoxide level
ANS: A, B, C, E
Rationale: Nicotinic acid in tobacco triggers the release of catecholamines (hormones that are released due to stress), which raise the heart rate and blood pressure and cause coronary arteries to constrict. This increases the risk of CAD and sudden cardiac death. Tobacco use also increases oxidation of low-density lipoprotein (good) cholesterol, which results in increased platelet adhesion and thrombus formation. Ischemia and reduced contractility can result in the increase in carbon monoxide levels and decreased oxygenation of the myocardium.
A 17-year-old client is being treated in the intensive care unit after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. Which type of cardiomyopathy is particularly common among young people who appear otherwise healthy?
A. Dilated cardiomyopathy (DCM)
B. Arrhythmogenic right ventricular cardiomyopathy (ARVC)
C. Hypertrophic cardiomyopathy (HCM)
D. Restrictive or constrictive cardiomyopathy (RCM)
ANS: C
Rationale: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.
A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.
A. Promote truthful communication.
B. Avoid asking the client to make decisions.
C. Teach the client coping strategies.
D. Administer benzodiazepines as prescribed.
E. Provide positive reinforcement.
ANS: A, C, E
Rationale: The nurse can assist the client to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the client practice appropriate strategies, and giving positive reinforcement when appropriate. The client may benefit from being able to make decisions regarding his or her care. Benzodiazepines may be needed for short-term management of anxiety, but they are not used to enhance coping.