nurs 400 unit 4 questions and answers latest updat
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Solution 2024/2025
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NURS 400 Unit 4 Questions and Answers Latest
Update
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.
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.
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
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Pepper
consistent with the early stage of compensation?
A) Increased urine output
B) Decreased heart rate
C) Hyperactive bowel sounds
D) Cool, clammy skin
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
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.
B
, Solution 2024/2025
Pepper
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
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
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
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Pepper
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
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.
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
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