NU 424: MS TEST WITH COMPLETE SOLUTIONS
Shock - ANSWER -alteration in compensatory mechanisms
-dec circulatory perfusion
-dec respiratory perfusion
-inc coagulation
-stimulation of the inflammatory responses: multiple organs failing
Tissue oxygenation and perfusion - ANSWER -delicate balance
-cells usually take up 25% of oxygen delivered
-cells can't extract enough oxygen:
1. anaerobic metabolism occurs
2. leads to lactic acidosis
3. cellular death can occur if this process isn't reversed
Inc in SVR - ANSWER The nurse suspects that a patient injured in a motor vehicle
accident is going into hypovolemic shock. Which of the following compensatory
mechanisms will help maintain a patient's blood pressure?
A. Increased urinary output
B. Decreased respiratory effort
C. Decreased preload
D. Increase in systemic vascular resistance (SVR)
Nonprogressive stage (stage 1) - ANSWER -shock stage
-VS: relatively normal
-cerebral perfusion: intact
-reversible: yes
Progressive stage (stage 2) - ANSWER -shock stage
-VS: noticeable changes; tachycardia and tachypnea (hemo: low BP)
-cerebral perfusion: change in LOC
,-reversible: yes, if recognized and treated appropriately
Irreversible (stage 3) - ANSWER -shock stage
-VS: temp down, pulse down, respirations down, hypotensive
-cerebral perfusion: profound dec in cerebral perfusion
-reversible: no
Hypovolemic - ANSWER -classification of shock
-burns
-hemorrhage
-severe dehydration
Pathophysiology of hypovolemic shock - ANSWER -dec circulating volume stimulates
SNS: inc myocardial demand, inc oxygen consumption, result is organ failure
-blood is shunted to heart and brain: kidney (first sign: dec UO), liver, and gut suffers
S/S depend on volume lost - ANSWER -hypovolemic shock
-assessment data: change in LOC, tachypnea, cool clammy skin, tachycardia,
hypotension (with >30% blood loss), dec UO
-lab data: serum lactate, serial ABGs, Hgb and Hct, coagulation profiles
Tx of hypovolemic shock - ANSWER -fluid resuscitation
-crystalloid and colloid complications: dilutional coagulopathy, dilutional
thrombocytopenia, hypothermia, inc hemorrhage, dec blood viscosity, pulmonary
edema, intracranial hypertension (pts with traumatic brain injury)
-packed RBCs complications: acidosis (banked blood pH 6.9-7.1), left shift on
oxyhemoglobin dissociation curve (banked blood deficient in 2,3-DPG; takes 24 hours
for oxygenation to occur), hyperkalemia, immunologic and infectious complications
Nursing mgmt. during fluid resuscitation (hypovolemic shock) - ANSWER -deliver
warmed fluids through large-bore (14-18 G) IV(s)
-monitor for fluid overload
-elevate lower extremities
-monitoring: VS, O2 sat, LOC, UO and labs
Cardiogenic - ANSWER -classification of shock
-pump failure
, -most often after acute MI
Cardiogenic shock - ANSWER -dec myocardial contraction
-dec in oxygenation to the tissues
-most significant cause is MI (40% of left ventricular mass infarction)
-often occurs at home
-other causes: ruptured papillary muscle, ventricular septal defect/rupture,
cardiomyopathy, valvular disease, dysrhythmias
S/S of cardiogenic shock - ANSWER -assessments: identify who is at high risk (MI, EF
<35%, DM, elderly), chest pain, thready rapid pulses, distended neck veins, pulmonary
congestion (crackles, gurgles, hemoptysis)
-labs/diagnostics: elevated cardiac enzymes (troponin, CPK-MB), BNP, ECG changes,
echocardiography, pulmonary artery pressures
Tx and nursing care of cardiogenic shock - ANSWER -fluids, diuretics, nitrates
-monitor and replace electrolytes, especially K+, Ca+, Mg
-narcotic analgesics: monitor SaO2
-treat rhythm disturbances
-possible cardioversion and pacing
-pulmonary artery pressure monitoring
-left ventricular assistive devices: IABP, LVAD
Medications for cardiogenic shock - ANSWER -beta-blockers
-dopamine
-dobutamine
-sodium nitroprusside
-nitroglycerin
-ACE inhibitors
Distributive - ANSWER -classification of shock
-spinal cord injury
-sepsis
-anaphylaxis
Shock - ANSWER -alteration in compensatory mechanisms
-dec circulatory perfusion
-dec respiratory perfusion
-inc coagulation
-stimulation of the inflammatory responses: multiple organs failing
Tissue oxygenation and perfusion - ANSWER -delicate balance
-cells usually take up 25% of oxygen delivered
-cells can't extract enough oxygen:
1. anaerobic metabolism occurs
2. leads to lactic acidosis
3. cellular death can occur if this process isn't reversed
Inc in SVR - ANSWER The nurse suspects that a patient injured in a motor vehicle
accident is going into hypovolemic shock. Which of the following compensatory
mechanisms will help maintain a patient's blood pressure?
A. Increased urinary output
B. Decreased respiratory effort
C. Decreased preload
D. Increase in systemic vascular resistance (SVR)
Nonprogressive stage (stage 1) - ANSWER -shock stage
-VS: relatively normal
-cerebral perfusion: intact
-reversible: yes
Progressive stage (stage 2) - ANSWER -shock stage
-VS: noticeable changes; tachycardia and tachypnea (hemo: low BP)
-cerebral perfusion: change in LOC
,-reversible: yes, if recognized and treated appropriately
Irreversible (stage 3) - ANSWER -shock stage
-VS: temp down, pulse down, respirations down, hypotensive
-cerebral perfusion: profound dec in cerebral perfusion
-reversible: no
Hypovolemic - ANSWER -classification of shock
-burns
-hemorrhage
-severe dehydration
Pathophysiology of hypovolemic shock - ANSWER -dec circulating volume stimulates
SNS: inc myocardial demand, inc oxygen consumption, result is organ failure
-blood is shunted to heart and brain: kidney (first sign: dec UO), liver, and gut suffers
S/S depend on volume lost - ANSWER -hypovolemic shock
-assessment data: change in LOC, tachypnea, cool clammy skin, tachycardia,
hypotension (with >30% blood loss), dec UO
-lab data: serum lactate, serial ABGs, Hgb and Hct, coagulation profiles
Tx of hypovolemic shock - ANSWER -fluid resuscitation
-crystalloid and colloid complications: dilutional coagulopathy, dilutional
thrombocytopenia, hypothermia, inc hemorrhage, dec blood viscosity, pulmonary
edema, intracranial hypertension (pts with traumatic brain injury)
-packed RBCs complications: acidosis (banked blood pH 6.9-7.1), left shift on
oxyhemoglobin dissociation curve (banked blood deficient in 2,3-DPG; takes 24 hours
for oxygenation to occur), hyperkalemia, immunologic and infectious complications
Nursing mgmt. during fluid resuscitation (hypovolemic shock) - ANSWER -deliver
warmed fluids through large-bore (14-18 G) IV(s)
-monitor for fluid overload
-elevate lower extremities
-monitoring: VS, O2 sat, LOC, UO and labs
Cardiogenic - ANSWER -classification of shock
-pump failure
, -most often after acute MI
Cardiogenic shock - ANSWER -dec myocardial contraction
-dec in oxygenation to the tissues
-most significant cause is MI (40% of left ventricular mass infarction)
-often occurs at home
-other causes: ruptured papillary muscle, ventricular septal defect/rupture,
cardiomyopathy, valvular disease, dysrhythmias
S/S of cardiogenic shock - ANSWER -assessments: identify who is at high risk (MI, EF
<35%, DM, elderly), chest pain, thready rapid pulses, distended neck veins, pulmonary
congestion (crackles, gurgles, hemoptysis)
-labs/diagnostics: elevated cardiac enzymes (troponin, CPK-MB), BNP, ECG changes,
echocardiography, pulmonary artery pressures
Tx and nursing care of cardiogenic shock - ANSWER -fluids, diuretics, nitrates
-monitor and replace electrolytes, especially K+, Ca+, Mg
-narcotic analgesics: monitor SaO2
-treat rhythm disturbances
-possible cardioversion and pacing
-pulmonary artery pressure monitoring
-left ventricular assistive devices: IABP, LVAD
Medications for cardiogenic shock - ANSWER -beta-blockers
-dopamine
-dobutamine
-sodium nitroprusside
-nitroglycerin
-ACE inhibitors
Distributive - ANSWER -classification of shock
-spinal cord injury
-sepsis
-anaphylaxis
