Exam (elaborations)
Test Questions 16.L Shock & Detailed Answers
- Course
- Capstone: Shock
- Institution
- University Of California - San Francisco
Test Questions 16.L Shock & Detailed Answers
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Test Questions 16.L Shock & Detailed AnswersHich assessment findings support the nurse's concern that a client is experiencing
hypovolemic shock? Select all that apply.
A) Slight increase in pulse
B) Dry, warm skin
C) Increased urine output
D) Normal respirations
E) Slight decrease in blood pressure - ANS Answer: A, D, E
Explanation: Manifestations of early hypovolemic shock include a slight increase in
pulse, normal respirations, and normal to slightly decreased blood pressure.
Manifestations also include cool, moist skin and a slight decrease in urine output.
A school-age client with a history of multiple allergies is prescribed epinephrine
(EpiPen™) for prevention of anaphylactic shock. The client's mother says to the
nurse, "I thought shock was about heart failure." Which response by the nurse is
the most appropriate?
A) "Allergic response is the most fatal type of shock; other types involve loss of
blood, heart failure, and liver failure."
B) "Heart failure is the most serious kind of shock; others include infection, kidney
failure, and loss of blood."
C) "There are many kinds of shock that also include infection, nervous system
damage, and loss of blood."
D) "There are many kinds of shock: heart failure, nervous system damage, loss of
blood, and respiratory failure." - ANS Answer: C Explanation: Obvious bleeding
, suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent
infection may indicate septic shock; and a history of allergies with a sudden onset
of symptoms may suggest anaphylactic shock. Liver failure, kidney failure, and
respiratory failure are not types of shock.
A client who is taking beta-adrenergic blockers for angina is experiencing
hypovolemic shock. Which does the nurse anticipate being the priority
collaborative intervention for this client?
A) Administering analgesics for control of pain
B) Assessing the cause of bleeding
C) Providing replacement of volume
D) Establishing invasive cardiac monitoring - ANS Answer: D
Explanation: Clients who take beta blockers may not present with tachycardia as
an early indicator of shock. These individuals will require early invasive monitoring
to avoid excessive or inadequate volume restoration. Replacement of volume
would occur after invasive cardiac monitoring is established. Pain would be a
consideration but would not be attended to as a first priority. Assessing the cause
of bleeding would also occur after establishing invasive cardiac monitoring.
The nurse has just completed the assessment of a client admitted with a gunshot
wound to the femoral artery. Which is the priority nursing diagnosis for this client?
A) Deficient Fluid Volume
B) Ineffective Coping
C) Ineffective Airway Clearance
D) Decreased Cardiac Output - ANS Answer: D
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