MDC 4 Module 7+8 Shock, Sepsis, MODS
A client with a history of depression is brought to the ED after overdosing on Valium. This client
is at risk for developing which type of distributive shock?
a.hypovolemic shock
b.anaphylactic shock
c.septic shock
d.neurogenic shock - correct answer d.neurogenic shock
When a patient in shock is receiving fluid replacement, what should the nurse monitor
frequently? (Select all that apply.)
a.Vital signs
b.Ability to perform range of motion exercises
c.Mental status
d.Visual acuity
e.Urinary output - correct answer a.Vital signs
c.Mental status
e.Urinary output
A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple
organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking
the nurses to identify which client would be at highest risk for MODS. It would be the client
who is experiencing septic shock and is
a.An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic
infection
b.A young female adolescent who developed shock from tampon use during menses
c.An older adult man with end-stage renal disease and an infected dialysis access site
,d.A middle-aged woman with metastatic breast cancer and a BMI of 26 - correct answer c.An
older adult man with end-stage renal disease and an infected dialysis access site
The nurse is administering a medication to the client with a positive inotropic effect. Which
action of the medication does the nurse anticipate?
a.Increase the force of myocardial contraction
b.Slow the heart rate
c.Dilate the bronchial tree
d.Depress the central nervous system - correct answer a.Increase the force of myocardial
contraction
The nursing instructor is discussing shock with the senior nursing students. The instructor tells
the students that shock is a life-threatening condition. What else should the instructor tell the
students about shock?
a.It begins when peripheral blood flow is inadequate.
b.It is a component of any trauma.
c.It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.
d.It causes respiratory distress syndrome. - correct answer c.It occurs when arterial blood flow
and oxygen delivery to tissues and cells are inadequate.
The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical
findings indicate a pre-shock condition, which is evidenced by:
a.Cold, clammy skin and tachycardia.
b.A heart rate of 140.
c.Crackles and shallow breathing.
d.A systolic blood pressure of 75 mm Hg. - correct answer a.Cold, clammy skin and tachycardia.
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The
client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is
not responding to treatment. In this stage, it is most important for the nurse to
a.Encourage the family to touch and talk to the client.
, b.Inform the family that everything is being done to assist with the client's survival.
c.Open up discussion among the family members about nursing home placement.
d.Contact a spiritual advisor to provide comfort to the family. - correct answer a.Encourage the
family to touch and talk to the client.
The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in
by the mother. The child was stung by a bee and is allergic to bee venom. The child is now
having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What
does the nurse suspect is wrong with this child?
a.The child is having an allergic reaction and going into anaphylactic shock.
b.The child is having an allergic reaction and going into cardiogenic shock.
c.The child is having an allergic reaction and going into neurogenic shock.
d.The child is having an allergic reaction and going into obstructive shock. - correct answer
a.The child is having an allergic reaction and going into anaphylactic shock.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the
client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified
by the neighbor. Which nursing action is helpful while waiting for the ambulance?
a.Place a cool compress on head.
b.Shake the client to arouse.
c.Cover the client with a blanket.
d.Elevate the legs higher than the heart. - correct answer d.Elevate the legs higher than the
heart.
What priority intervention can the nurse provide to decrease the incidence of septic shock for
patients who are at risk?
a.Use strict hand hygiene techniques.
b.Administer prophylactic antibiotics for all patients at risk.
c.Insert indwelling catheters for incontinent patients.
A client with a history of depression is brought to the ED after overdosing on Valium. This client
is at risk for developing which type of distributive shock?
a.hypovolemic shock
b.anaphylactic shock
c.septic shock
d.neurogenic shock - correct answer d.neurogenic shock
When a patient in shock is receiving fluid replacement, what should the nurse monitor
frequently? (Select all that apply.)
a.Vital signs
b.Ability to perform range of motion exercises
c.Mental status
d.Visual acuity
e.Urinary output - correct answer a.Vital signs
c.Mental status
e.Urinary output
A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple
organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking
the nurses to identify which client would be at highest risk for MODS. It would be the client
who is experiencing septic shock and is
a.An 8-year-old boy who underwent an appendectomy and then incurred an iatrogenic
infection
b.A young female adolescent who developed shock from tampon use during menses
c.An older adult man with end-stage renal disease and an infected dialysis access site
,d.A middle-aged woman with metastatic breast cancer and a BMI of 26 - correct answer c.An
older adult man with end-stage renal disease and an infected dialysis access site
The nurse is administering a medication to the client with a positive inotropic effect. Which
action of the medication does the nurse anticipate?
a.Increase the force of myocardial contraction
b.Slow the heart rate
c.Dilate the bronchial tree
d.Depress the central nervous system - correct answer a.Increase the force of myocardial
contraction
The nursing instructor is discussing shock with the senior nursing students. The instructor tells
the students that shock is a life-threatening condition. What else should the instructor tell the
students about shock?
a.It begins when peripheral blood flow is inadequate.
b.It is a component of any trauma.
c.It occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate.
d.It causes respiratory distress syndrome. - correct answer c.It occurs when arterial blood flow
and oxygen delivery to tissues and cells are inadequate.
The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical
findings indicate a pre-shock condition, which is evidenced by:
a.Cold, clammy skin and tachycardia.
b.A heart rate of 140.
c.Crackles and shallow breathing.
d.A systolic blood pressure of 75 mm Hg. - correct answer a.Cold, clammy skin and tachycardia.
A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The
client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is
not responding to treatment. In this stage, it is most important for the nurse to
a.Encourage the family to touch and talk to the client.
, b.Inform the family that everything is being done to assist with the client's survival.
c.Open up discussion among the family members about nursing home placement.
d.Contact a spiritual advisor to provide comfort to the family. - correct answer a.Encourage the
family to touch and talk to the client.
The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in
by the mother. The child was stung by a bee and is allergic to bee venom. The child is now
having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What
does the nurse suspect is wrong with this child?
a.The child is having an allergic reaction and going into anaphylactic shock.
b.The child is having an allergic reaction and going into cardiogenic shock.
c.The child is having an allergic reaction and going into neurogenic shock.
d.The child is having an allergic reaction and going into obstructive shock. - correct answer
a.The child is having an allergic reaction and going into anaphylactic shock.
The community health nurse finds the client collapsed outdoors. The nurse assesses that the
client is shallow breathing and has a weak pulse. Emergency medical services (EMS) is notified
by the neighbor. Which nursing action is helpful while waiting for the ambulance?
a.Place a cool compress on head.
b.Shake the client to arouse.
c.Cover the client with a blanket.
d.Elevate the legs higher than the heart. - correct answer d.Elevate the legs higher than the
heart.
What priority intervention can the nurse provide to decrease the incidence of septic shock for
patients who are at risk?
a.Use strict hand hygiene techniques.
b.Administer prophylactic antibiotics for all patients at risk.
c.Insert indwelling catheters for incontinent patients.
