CHAPTER 11 SHOCK, SEPSIS, AND MULTIPLE ORGAN
DYSFUNCTION SYNDROME QUESTIONS WITH DETAILED
VERIFIED AND 100% ACCURATE ANSWERS
A nurse is assessing a client who is experiencing significant stress due to
septicemia. The nurse should... Correct Answers -Administer oxygen
therapy
- Monitor temperature
- Obtain the lactate level
Rationale: The nurse should expect to administer oxygen therapy to
support perfusion, monitor temperature to assess metabolic response,
and obtain lactate levels, which serve as a critical predictor of the client's
metabolic stress response. The nurse should not place a client with
septicemia in a prone position because this would lead to further
respiratory compromise. The nurse should not increase PO fluid intake
because this would also lead to respiratory compromise and fluid
volume overload.
The nurse observes a patient in the progressive stage of shock with
blood in the nasogastric tube and when connected to suction. What does
the nurse understand could be occurring with this patient?
- The patient is having a reaction to the vasoconstricting medications
- The patient has bleeding esophageal varices
- The patient has a tumor in the esophagus
- The patient has developed a stress ulcer that is bleeding Correct
Answers The patient has developed a stress ulcer that is bleeding.
Rationale: GI ischemia can cause stress ulcers in the stomach during the
progressive stage of shock, putting the patient at risk for GI bleeding.
The patient would not be on vasoconstrictors but vasodilators, to
,improve perfusion, and such a reaction would be unlikely. There is no
indication that the patient has a tumor or varices in the esophagus.
The nurse is using continuous central venous oximetry (ScvO2) to
monitor the blood oxygen saturation of a patient in shock. What value
would the nurse document as normal for the patient?
- 60%
- 50%
- 70%
- 40% Correct Answers 70%
Rationale: Continuous central venous oximetry (ScvO2) monitoring may
be used to evaluate mixed venous blood oxygen saturation and severity
of tissue hypoperfusion states. A central catheter is introduced into the
superior vena cava (SVC), and a sensor on the catheter measures the
oxygen saturation of the blood in the SVC as blood returns to the heart
and pulmonary system for re-oxygenation. A normal ScvO2 value is
70%.
At what point in shock does metabolic acidosis occur?
- Late
- Irreversible
- Decompensation (Progressive)
- Early) Correct Answers Decompensation (Progressive)
Rationale: The decompensation or progressive stage occurs as
compensatory mechanisms fail. The client's condition spirals into
cellular hypoxia, coagulation defects, and cardiovascular changes. As
,the energy supply falls below the demand, pyruvic and lactic acids
increase, causing metabolic acidosis.
The nurse is caring for a client who is in neurogenic shock. The nurse
knows that this is a subcategory of what kind of shock?
- Distributive
- Hypovolemic
- Obstructive
- Carcinogenic Correct Answers Distributive
Rationale: Three types of distributive shock are neurogenic, septic, and
anaphylactic shock.
The nurse provides care for a client who is diagnosed with shock and
who is at risk for multiple organ dysfunction syndrome (MODS).
Based on the first organ system that is typically affected by MODS, the
nurse prioritizes monitoring the client for symptoms of ... as evidenced
by ...
- hepatic dysfunction, left-sided weakness
- acute lung injury, shortness of breath
- hyper-metabolic state, an increase in heart rate
- renal dysfunction, a drop in blood pressure Correct Answers acute lung
injury, shortness of breath
Rationale: In multiple organ dysfunction syndrome (MODS), the
sequence of organ dysfunction varies depending on the client's primary
illness and comorbidities before experiencing shock; however, the lungs
are often the first organ to show dysfunction.
, The client who is at risk for MODS should be assessed for the first
symptom that often accompanies this diagnosis, which is acute lung
injury (ALI). Symptoms associated with ALI include shortness of breath
(i.e., dyspnea) and respiratory failure.
Although the first presentation of MODS is often ALI, the client is also
at risk for developing a hypermetabolic state, hepatic dysfunction, and
renal dysfunction. Although the client may experience a drop in blood
pressure and an increased heart rate with MODS, the heart and
circulatory system are not affected first by this diagnosis. Left-sided
weakness is associated with a right-sided stroke and not MODS.
What can the nurse include in the plan of care to ensure early
intervention along the continuum of shock to improve the client's
prognosis? Select all that apply.
- Administer intravenous fluids
- Administer prophylactic packed red blood cells
- Monitor for changes in vital signs
- Identify the cause of shock
- Administer vasoconstrictive medications Correct Answers - Identify
the cause of shock
- Administer intravenous fluids
- Monitor for changes in vital signs
Rationale: Early intervention along the continuum of shock is the key to
improving the client's prognosis. The nurse must systematically assess
the client at risk for shock, recognizing subtle clinical signs of the
compensatory stage before the client's BP drops. Early interventions
include identifying the cause of shock, administering intravenous (IV)
fluids and oxygen, and obtaining necessary laboratory tests to rule out
DYSFUNCTION SYNDROME QUESTIONS WITH DETAILED
VERIFIED AND 100% ACCURATE ANSWERS
A nurse is assessing a client who is experiencing significant stress due to
septicemia. The nurse should... Correct Answers -Administer oxygen
therapy
- Monitor temperature
- Obtain the lactate level
Rationale: The nurse should expect to administer oxygen therapy to
support perfusion, monitor temperature to assess metabolic response,
and obtain lactate levels, which serve as a critical predictor of the client's
metabolic stress response. The nurse should not place a client with
septicemia in a prone position because this would lead to further
respiratory compromise. The nurse should not increase PO fluid intake
because this would also lead to respiratory compromise and fluid
volume overload.
The nurse observes a patient in the progressive stage of shock with
blood in the nasogastric tube and when connected to suction. What does
the nurse understand could be occurring with this patient?
- The patient is having a reaction to the vasoconstricting medications
- The patient has bleeding esophageal varices
- The patient has a tumor in the esophagus
- The patient has developed a stress ulcer that is bleeding Correct
Answers The patient has developed a stress ulcer that is bleeding.
Rationale: GI ischemia can cause stress ulcers in the stomach during the
progressive stage of shock, putting the patient at risk for GI bleeding.
The patient would not be on vasoconstrictors but vasodilators, to
,improve perfusion, and such a reaction would be unlikely. There is no
indication that the patient has a tumor or varices in the esophagus.
The nurse is using continuous central venous oximetry (ScvO2) to
monitor the blood oxygen saturation of a patient in shock. What value
would the nurse document as normal for the patient?
- 60%
- 50%
- 70%
- 40% Correct Answers 70%
Rationale: Continuous central venous oximetry (ScvO2) monitoring may
be used to evaluate mixed venous blood oxygen saturation and severity
of tissue hypoperfusion states. A central catheter is introduced into the
superior vena cava (SVC), and a sensor on the catheter measures the
oxygen saturation of the blood in the SVC as blood returns to the heart
and pulmonary system for re-oxygenation. A normal ScvO2 value is
70%.
At what point in shock does metabolic acidosis occur?
- Late
- Irreversible
- Decompensation (Progressive)
- Early) Correct Answers Decompensation (Progressive)
Rationale: The decompensation or progressive stage occurs as
compensatory mechanisms fail. The client's condition spirals into
cellular hypoxia, coagulation defects, and cardiovascular changes. As
,the energy supply falls below the demand, pyruvic and lactic acids
increase, causing metabolic acidosis.
The nurse is caring for a client who is in neurogenic shock. The nurse
knows that this is a subcategory of what kind of shock?
- Distributive
- Hypovolemic
- Obstructive
- Carcinogenic Correct Answers Distributive
Rationale: Three types of distributive shock are neurogenic, septic, and
anaphylactic shock.
The nurse provides care for a client who is diagnosed with shock and
who is at risk for multiple organ dysfunction syndrome (MODS).
Based on the first organ system that is typically affected by MODS, the
nurse prioritizes monitoring the client for symptoms of ... as evidenced
by ...
- hepatic dysfunction, left-sided weakness
- acute lung injury, shortness of breath
- hyper-metabolic state, an increase in heart rate
- renal dysfunction, a drop in blood pressure Correct Answers acute lung
injury, shortness of breath
Rationale: In multiple organ dysfunction syndrome (MODS), the
sequence of organ dysfunction varies depending on the client's primary
illness and comorbidities before experiencing shock; however, the lungs
are often the first organ to show dysfunction.
, The client who is at risk for MODS should be assessed for the first
symptom that often accompanies this diagnosis, which is acute lung
injury (ALI). Symptoms associated with ALI include shortness of breath
(i.e., dyspnea) and respiratory failure.
Although the first presentation of MODS is often ALI, the client is also
at risk for developing a hypermetabolic state, hepatic dysfunction, and
renal dysfunction. Although the client may experience a drop in blood
pressure and an increased heart rate with MODS, the heart and
circulatory system are not affected first by this diagnosis. Left-sided
weakness is associated with a right-sided stroke and not MODS.
What can the nurse include in the plan of care to ensure early
intervention along the continuum of shock to improve the client's
prognosis? Select all that apply.
- Administer intravenous fluids
- Administer prophylactic packed red blood cells
- Monitor for changes in vital signs
- Identify the cause of shock
- Administer vasoconstrictive medications Correct Answers - Identify
the cause of shock
- Administer intravenous fluids
- Monitor for changes in vital signs
Rationale: Early intervention along the continuum of shock is the key to
improving the client's prognosis. The nurse must systematically assess
the client at risk for shock, recognizing subtle clinical signs of the
compensatory stage before the client's BP drops. Early interventions
include identifying the cause of shock, administering intravenous (IV)
fluids and oxygen, and obtaining necessary laboratory tests to rule out
