Test Bank NUR 201 Caring for Clients in Shock Questions & Answers & Rationale,100% CORRECT
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NUR 201
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NUR 201
Test Bank NUR 201 Caring for Clients in Shock Questions & Answers & Rationale
1. You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?
A) A rapid, bounding pulse
B) A ...
test bank nur 201 caring for clients in shock questions amp answers amp rationale
1 you are the nurse caring for a client in septic shock you know to closely monitor your client what finding wo
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Test Bank NUR 201Caring for Clients in Shock Questions & Answers &
Rationale
1. You are the nurse caring for a client in septic shock. You know to
closely monitor your client. What finding would you observe when the
client's condition is in its initial stages?
A) A rapid, bounding pulse
B) A slow but steady pulse
C) A weak and thready pulse
D) A slow and imperceptible pulse
Ans: A
Feedback:
A rapid, bounding pulse is observed in a client in the initial stages of septic
shock. In case of hypovolemic shock, the pulse volume becomes weak and
thready and circulating volume diminishes in the initial stage. In the later
stages when the circulating volume has severely diminished, the pulse
becomes slow and imperceptible, and pulse rhythm changes from regular to
irregular.
2. You are caring for a client with shock. You are concerned about
hypoxemia and metabolic acidosis with your client. What finding should
you analyze for evidence of hypoxemia and metabolic acidosis in a client
with shock?
A) Serum thyroid level findings
B) Arterial blood gas (ABG) findings
C) Red blood cells (RBCs) and hemoglobin count findings
D) White blood cell count findings
Ans: B
Feedback:
Analysis of ABG findings is essential for evidence of hypoxemia and
metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic
shock and can lead to poor oxygenation. An elevated white blood cell count
supports septic shock. Serum thyroid level findings do not help determine
the presence of hypoxemia or metabolic acidosis.
3. You are the nurse caring for a client with shock accompanied by lung
congestion. How would you position this client?
A) Completely supine
B) Low Fowler's with legs flat
C) Supine with lower extremities raised to approximately 45º
D) Semi-Fowler's with lower extremities
raised to approximately 15º Ans: D
Feedback:
For a client with shock accompanied by lung congestion, the nurse should
raise the client's upper body to approximately 45º and lower extremities to
approximately 15º. Elevating the upper body lowers the diaphragm and
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, provides more room for lung expansion and gas exchange. Elevating the
head reduces intracranial pressure. Elevating the legs promotes blood
perfusion to the heart, lungs, and brain. Therefore, options A, B, and C are
incorrect.
4. You are a nursing student preparing to care for an ICU client with
shock. Your instructor asks you to name the different categories of shock.
Which of the following is a category of shock?
A) Hypervolemic
B) Distributive
C) Restrictive
D) Cardiotonic
Ans: B
Feedback:
The four main categories of shock are hypovolemic, distributive, obstructive,
and cardiogenic, depending on the cause. This makes options A, C, and D
incorrect.
5. You are caring for a client who is in neurogenic shock. You know that
this is a subcategory of what kind of shock?
A) Obstructive
B) Hypovolemic
C) Carcinogenic
D) Distributive
Ans: D
Feedback:
Three types of distributive shock are neurogenic, septic, and anaphylactic
shock. There is no such thing as carcinogenic shock. Obstructive and
hypovolemic shock do not have subcategories.
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, 6. You are a student nurse being precepted in the ICU. You are caring for
a client in the compensatory stage of shock who is hypovolemic. Which
compensatory mechanism is most important in the reabsorption and
retention of fluid in the body?
A) Activation of renin-angiotensin-aldosterone system
B) Secretion of epinephrine and norepinephrine
C) Production of antidiuretic hormone and corticosteroid hormones
D) Release of catecholamines
Ans: C
Feedback:
Thus, they play an active role in controlling sodium and water balance. Both
ADH and corticosteroid hormones, then, promote fluid reabsorption and
retention. The renin-angiotensin-aldosterone system is a mechanism that
restores blood pressure (BP) when circulating volume is diminished. The
release of catecholamines stimulates secretion of epinephrine and
norepinephrine.
7. You are assessing a 6-year-old little girl in the emergency department
(ED) who was brought in by her mother. She was stung by a bee and is
allergic to bee venom. The child is now having trouble breathing. She is
vasodilated, hypotensive, and has broken out in hives. What do you suspect
is wrong with this child?
A) She is having an allergic reaction and going into cardiogenic shock.
B) She is having an allergic reaction and going into anaphylactic shock.
C) She is having an allergic reaction and going into neurogenic shock.
D) She is having an allergic reaction and
going into obstructive shock. Ans: B
Feedback:
Anaphylactic shock is a severe allergic reaction that follows exposure to a
substance to which a person is extremely sensitive (see Ch. 34). Common
allergic substances include bee venom, latex, fish, nuts, and penicillin. The
body's immune response to the allergic substance causes mast cells in the
connective tissues, bronchi, and gastrointestinal tract to release histamine
and other chemicals. The results are vasodilatation, increased capillary
permeability accompanied by swelling of the airway and subcutaneous
tissues, hypotension, and hives or an itchy rash. Cardiogenic shock,
neurogenic shock, and obstructive shock would not begin with vasodilation,
swelling of the airway, and hives.
Therefore, options A, C, and D are incorrect.
This study source was downloaded by 100000802531269 from CourseHero.com oPna0g9e-124-2022 09:35:54 GMT -05:00
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