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NUR 213 Exam – Questions & Verified Solutions
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NUR 213 Exam – Questions & Verified Solutions
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NUR 213 Exam – Questions & Verified SolutionsFailure of the heart to pump effectively due to a cardiac factor. Right Ans -
cardiogenic shock
A decrease in intravascular volume of at least 15% to 30% Right Ans -
hypovolemic shock
Impairment of the heart to pump effectively as a result of a noncardiac factor
Right Ans - obstructive shock
Widespread vasodilation and increased capillary permeability, including
neurogenic, septic, and anaphylactic shock Right Ans - distributive shock
The mean arterial pressure (MAP) decreases 5 to 10 mmHg from the client's
baseline, mild vasoconstriction occurs, and the heart rate increases to
maintain cardiac output Right Ans - stage of shock (initial)
Vasoconstriction increases, the heart rate increases, the MAP decreases 10 to
15 mmHg from baseline, and the client experiences mild acidosis and mild
hyperkalemia. Right Ans - Stage of Shock: Compensatory
The MAP decreases more than 20 mmHg from baseline, the vital organs
experience hypoxia, and the client experiences moderate acidosis and
moderate hyperkalemia. Right Ans - Stages of Shock: Progressive
The client experiences severe tissue hypoxia, multiple organ dysfunction
syndrome (MODS), and possibly death. Right Ans - Stages of Shock
(Refractory)
Educate the client about ways to reduce the risk of a myocardial infarction
(MI), such as exercise, diet, stress reduction, and smoking cessation. Right
Ans - Cardiogenic shock
Advise the client to drink plenty of fluids when exercising or when in hot
weather.
, Advise the client to obtain early medical attention with illness or trauma and
with any evidence of dehydration or bleeding.
Educate the client about the manifestations of dehydration, including thirst,
decreased urine output, and dizziness. Right Ans - Hypovolemic Shock
Educate the client about wearing seat belts and helmets, and the use of
caution with dangerous equipment, machinery, or activities. Right Ans -
Obstructive/neurogenic/hypovolemic shock
Advise the client to obtain early medical attention with evidence of an
infection (localized redness, swelling, drainage, fever, urinary frequency and
burning).
Advise the client to complete the entire course of antibiotics as directed.
SOFA - Sequential Organ Failure Assessment (also called Sepsis-Related Organ
Failure Assessment Score - recommended tool for all hospitalized clients who
have infectionsParameters related to cardiovascular status, respiration, liver
function, renal function, coagulation, and central nervous system
function.Sepsis and risk for septic shock are suspected if score indicates organ
dysfunction. Right Ans - Septic shock
Advise the client to wear a medical identification wristband, avoid allergens,
and to have an epinephrine pen available at all times. QS
Teach the client and family how to use the epinephrine pen and to be alert to
early manifestations of an allergic reaction. Right Ans - Anaphylactic shock
Cardiac pump failure occurs due to a direct cardiac cause, such as MI
(especially anterior wall infarction), heart failure, cardiomyopathy,
dysrhythmias, and valvular rupture or stenosis.
Older adult clients are at increased risk for MI and cardiomyopathy. Right
Ans - Cardiogenic shock risk factors
Excessive fluid loss from diuresis, vomiting, or diarrhea; or blood loss
secondary to surgery, trauma, gynecologic/obstetric causes, burns, and
diabetic ketoacidosis.
Older adult clients are more prone to dehydration due to decreased fluid and
protein intake and the use of medications, such as diuretics. Minimal amounts
of fluid loss (vomiting, diarrhea) can cause the older adult client to become
dehydrated. Right Ans - Hypovolemic shock risk factors
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