Chapter 69 - Nursing Management: Shock,
SIRS, and MODS Exam Study Set
A client has a spinal cord injury at T4. Vital signs include falling blood pressure with
bradycardia. The nurse recognizes that the client is experiencing which of the following?
a. A relative hypervolemia
b. An absolute hypovolemia
c. Neurogenic shock from low blood flow
d. Neurogenic shock from massive vasodilation - ANSWER d
A 78-year-old man has confusion and temperature of 40°C. He has diabetes with
purulent drainage from his right heel. After an infusion of 3 L of normal saline solution,
his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and
shallow; CO 8 L/min; and PAOP 4 mm Hg. This client's symptoms are most likely
indicative of which of the following?
a. Sepsis
b. Septic shock
c. Multiple-organ dysfunction syndrome
d. Systemic inflammatory response syndrome - ANSWER b
Appropriate treatment modalities for the management of cardiogenic shock include
which of the following? (Select all that apply)
a. Dobutamine to increase myocardial contractility
b. Vasopressors to increase systemic vascular resistance
c. Circulatory assist devices such as an intra-aortic balloon pump
d. Corticosteroids to stabilize the cell wall in the infarcted myocardium
e. Trendelenburg positioning to facilitate venous return and increase preload -
ANSWER a,c
The most accurate assessment parameters for the nurse to use to determine adequate
tissue perfusion in the client with MODS are which of the following?
a. Blood pressure, pulse, and respirations
b. Breath sounds, blood pressure, and body temperature
c. Pulse pressure, level of consciousness, and pupillary response
d. Level of consciousness, urine output, and skin colour and temperature - ANSWER d
, The nurse is caring for a client in acute septic shock. Which of the following actions
should the nurse anticipate?
a. Administering osmotic and loop diuretics or both
b. Infusing large amounts of intravenous fluids
c. Administering intravenous diphenhydramine
d. Assisting with insertion of a ventricular assist device (VAD) - ANSWER b
The nurse is caring for a critically ill client who is being mechanically ventilated. Which
of the following findings indicate that the client is experiencing multiple organ
dysfunction syndrome (MODS)?
a. Increased gastrointestinal (GI) motility
b. Increased serum albumin
c. Decreased blood urea nitrogen (BUN)/creatinine ratio
d. Decreased respiratory compliance - ANSWER d
The nurse is caring for an older-adult client who has a massive gastrointestinal bleed
that has resulted in hypovolemic shock. Which of the following nursing diagnoses is
priority?
a. Acute pain
b. Impaired tissue integrity
c. Decreased cardiac output
d. Ineffective tissue perfusion - ANSWER d
Which of the following laboratory findings fits with a diagnosis of cardiogenic shock?
a. Decreased liver enzymes
b. Increased white blood cells
c. Increased blood urea nitrogen (BUN) and creatinine levels
d. Decreased red blood cells, hemoglobin, and hematocrit - ANSWER c
The nurse is caring for a client who has a localized infection that has progressed to the
point where septic shock is now suspected. Which of the following actions is appropriate
for this client?
a. Insulin infusion
b. Aggressive fluid resuscitation
c. Intravenous administration of epinephrine
d. Administration of nitrates and á-adrenergic blockers - ANSWER b
The nurse would recognize which of the following clinical manifestations as suggestive
of sepsis?
a. Respiratory rate of 7 breaths/minute
b. Hyperglycemia in the absence of diabetes
c. Sudden diuresis unrelated to drug therapy
d. Bradycardia with sudden increase in blood pressure - ANSWER b
A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central
venous
SIRS, and MODS Exam Study Set
A client has a spinal cord injury at T4. Vital signs include falling blood pressure with
bradycardia. The nurse recognizes that the client is experiencing which of the following?
a. A relative hypervolemia
b. An absolute hypovolemia
c. Neurogenic shock from low blood flow
d. Neurogenic shock from massive vasodilation - ANSWER d
A 78-year-old man has confusion and temperature of 40°C. He has diabetes with
purulent drainage from his right heel. After an infusion of 3 L of normal saline solution,
his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and
shallow; CO 8 L/min; and PAOP 4 mm Hg. This client's symptoms are most likely
indicative of which of the following?
a. Sepsis
b. Septic shock
c. Multiple-organ dysfunction syndrome
d. Systemic inflammatory response syndrome - ANSWER b
Appropriate treatment modalities for the management of cardiogenic shock include
which of the following? (Select all that apply)
a. Dobutamine to increase myocardial contractility
b. Vasopressors to increase systemic vascular resistance
c. Circulatory assist devices such as an intra-aortic balloon pump
d. Corticosteroids to stabilize the cell wall in the infarcted myocardium
e. Trendelenburg positioning to facilitate venous return and increase preload -
ANSWER a,c
The most accurate assessment parameters for the nurse to use to determine adequate
tissue perfusion in the client with MODS are which of the following?
a. Blood pressure, pulse, and respirations
b. Breath sounds, blood pressure, and body temperature
c. Pulse pressure, level of consciousness, and pupillary response
d. Level of consciousness, urine output, and skin colour and temperature - ANSWER d
, The nurse is caring for a client in acute septic shock. Which of the following actions
should the nurse anticipate?
a. Administering osmotic and loop diuretics or both
b. Infusing large amounts of intravenous fluids
c. Administering intravenous diphenhydramine
d. Assisting with insertion of a ventricular assist device (VAD) - ANSWER b
The nurse is caring for a critically ill client who is being mechanically ventilated. Which
of the following findings indicate that the client is experiencing multiple organ
dysfunction syndrome (MODS)?
a. Increased gastrointestinal (GI) motility
b. Increased serum albumin
c. Decreased blood urea nitrogen (BUN)/creatinine ratio
d. Decreased respiratory compliance - ANSWER d
The nurse is caring for an older-adult client who has a massive gastrointestinal bleed
that has resulted in hypovolemic shock. Which of the following nursing diagnoses is
priority?
a. Acute pain
b. Impaired tissue integrity
c. Decreased cardiac output
d. Ineffective tissue perfusion - ANSWER d
Which of the following laboratory findings fits with a diagnosis of cardiogenic shock?
a. Decreased liver enzymes
b. Increased white blood cells
c. Increased blood urea nitrogen (BUN) and creatinine levels
d. Decreased red blood cells, hemoglobin, and hematocrit - ANSWER c
The nurse is caring for a client who has a localized infection that has progressed to the
point where septic shock is now suspected. Which of the following actions is appropriate
for this client?
a. Insulin infusion
b. Aggressive fluid resuscitation
c. Intravenous administration of epinephrine
d. Administration of nitrates and á-adrenergic blockers - ANSWER b
The nurse would recognize which of the following clinical manifestations as suggestive
of sepsis?
a. Respiratory rate of 7 breaths/minute
b. Hyperglycemia in the absence of diabetes
c. Sudden diuresis unrelated to drug therapy
d. Bradycardia with sudden increase in blood pressure - ANSWER b
A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central
venous
