Exam (elaborations)
NURS 400 Unit 4.
- Module
- Cardiac exam nursing 400
- Institution
- Cardiac Exam Nursing 400
Exam of 58 pages for the course cardiac exam nursing 400 at cardiac exam nursing 400 (NURS 400 Unit 4.)
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NURS 400 Unit 4Chapter 18 Shock and Multiple Organ Dysfunction Syndrome - ANS-
1. A nurse in the ICU is planning the care of a patient who is being treated for shock.
Which of the following statements best describes the pathophysiology of this patients
health problem?
A) Blood is shunted from vital orgAns to peripheral areas of the body.
B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
C) Circulating blood volume is decreased with a resulting change in the osmotic
pressure gradient.
D) Hemorrhage occurs as a result of trauma, depriving vital orgAns of adequate
perfusion. - ANS-B
2. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing
the
patients care, the nurse should recognize that the patient is at risk for hypovolemic
shock
in which of the following circumstances?
A) Fluid volume circulating in the blood vessels decreases.
B) There is an uncontrolled increase in cardiac output.
C) Blood pressure regulation becomes irregular.
D) The patient experiences tachycardia and a bounding pulse. - ANS-A
3. The emergency nurse is admitting a patient experiencing a GI bleed who is believed
to
be in the compensatory stage of shock. What assessment finding would be most
consistent with the early stage of compensation?
A) Increased urine output
B) Decreased heart rate
C) Hyperactive bowel sounds
D) Cool, clammy skin - ANS-D
4. The nurse is caring for a patient who is exhibiting signs and symptoms of
hypovolemic
shock following injuries suffered in a motor vehicle accident. The nurse anticipates that
the physician will promptly order the administration of a crystalloid IV solution to
restore intravascular volume. In addition to normal saline, which crystalloid fluid is
commonly used to treat hypovolemic shock?
,A) Lactated Ringers
B) Albumin
C) Dextran
D) 3% NaCl - ANS-A
5. A patient who is in shock is receiving dopamine in addition to IV fluids. What principle
should inform the nurses care planning during the administration of a vasoactive drug?
A) The drug should be discontinued immediately after blood pressure increases.
B) The drug dose should be tapered down once vital signs improve.
C) The patient should have arterial blood gases drawn every 10 minutes during
treatment.
D) The infusion rate should be titrated according the patients subjective sensation of
adequate perfusion. - ANS-B
6. A nurse in the ICU receives report from the nurse in the ED about a new patient
being
admitted with a neck injury he received while diving into a lake. The ED nurse reports
that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm
and dry. What does the ICU nurse recognize that that patient is probably experiencing?
A) Anaphylactic shock
B) Neurogenic shock
C) Septic shock
D) Hypovolemic shock - ANS-B
7. The intensive care nurse caring for a patient in shock is planning assessments and
interventions related to the patients nutritional needs. What physiologic process
contributes to these increased nutritional needs?
A) The use of albumin as an energy source by the body because of the need for
increased adenosine triphosphate (ATP)
B) The loss of fluids due to decreased skin integrity and decreased stomach acids due
to increased parasympathetic activity
C) The release of catecholamines that creates an increase in metabolic rate and caloric
requirements
D) The increase in GI peristalsis during shock and the resulting diarrhea - ANS-C
8. The nurse is trAnsferring a patient who is in the progressive stage of shock into ICU
from
the medical unit. The medical nurse is aware that shock affects many organ systems
and
that nursing management of the patient will focus on what intervention?
,A) Reviewing the cause of shock and prioritizing the patients psychosocial needs
B) Assessing and understanding shock and the significant changes in assessment data
to guide the plan of care
C) Giving the prescribed treatment, but shifting focus to providing family time as the
patient is unlikely to survive
D) Promoting the patients coping skills in an effort to better deal with the physiologic
changes accompanying shock - ANS-B
9. When caring for a patient in shock, one of the major nursing goals is to reduce the
risk
that the patient will develop complications of shock. How can the nurse best achieve
this
goal?
A) Provide a detailed diagnosis and plan of care in order to promote the patients and
familys coping.
B) Keep the physician updated with the most accurate information because in cases of
shock the nurse often cannot provide relevant interventions.
C) Monitor for significant changes and evaluate patient outcomes on a scheduled
basis focusing on blood pressure and skin temperature.
D) Understand the underlying mechanisms of shock, recognize the subtle and more
obvious signs, and then provide rapid assessment. - ANS-D
10. The nurse is caring for a patient in the ICU who has been diagnosed with multiple
organ
dysfunction syndrome (MODS). The nurses plan of care should include which of the
following interventions?
A) Encouraging the family to stay hopeful and educating them to the fact that, in
nearly all cases, the prognosis is good
B) Encouraging the family to leave the hospital and to take time for themselves as
acute care of MODS patients may last for several months
C) Promoting communication with the patient and family along with addressing
endof-life issues
D) Discussing organ donation on a number of different occasions to allow the family
time to adjust to the idea - ANS-C
11. The acute care nurse is providing care for an adult patient who is in hypovolemic
shock.
The nurse recognizes that antidiuretic hormone (ADH) plays a significant role in this
health problem. What assessment finding will the nurse likely observe related to the role
of the ADH during hypovolemic shock?
, A) Increased hunger
B) Decreased thirst
C) Decreased urinary output
D) Increased capillary perfusion - ANS-C
12. The nurse is caring for a patient whose progressing infection places her at high risk
for
shock. What assessment finding would the nurse consider a potential sign of shock?
A) Elevated systolic blood pressure
B) Elevated mean arterial pressure (MAP)
C) Shallow, rapid respirations
D) Bradycardia - ANS-C
13. You are precepting a new graduate nurse in the ICU. You are collaborating in the
care of
a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock.
In light of this intervention, for what sign would you teach the new nurse to monitor the
patient?
A) Hypothermia
B) Bradycardia
C) Coffee ground emesis
D) Pain - ANS-A
14. The nurse is caring for a patient in the ICU whose condition is deteriorating. The
nurse
receives orders to initiate an infusion of dopamine. What would be the priority
assessment and interventions specific to the administration of vasoactive medications?
A) Frequent monitoring of vital signs, monitoring the central line site, and providing
accurate drug titration
B) Reviewing medications, performing a focused cardiovascular assessment, and
providing patient education
C) Reviewing the laboratory findings, monitoring urine output, and assessing for
peripheral edema
D) Routine monitoring of vital signs, monitoring the peripheral IV site, and providing
early discharge instructions - ANS-A
15. The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible
septic
shock. The nurses assessment reveals that the patient has a normal blood pressure,
increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurses
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