CEN Practice Questions often cover a wide range of emergency nursing topics.
Shock CEN Practice Questions - CEN Questions on Shock
Question 1.
Which of the following is the common denominator in all forms of shock?
(a) Large loss of blood volume
(b) Inadequate tissue perfusion
(c) Elevated heart rate
(d) Inadequate cardiac output
Answer:
(b) Inadequate tissue perfusion
Rationale:
The bottom line, physiologically, in all forms of shock is inadequate tissue perfusion. A large loss of blood volume is a cause of hypovolemic shock, and inadequate cardiac output is often a cause of cardiogenic shock. Tachycardia is a symptom seen in all forms of shock, except in neurogenic.
Question 2.
Which of the following is the most common form of shock?
(a) Hypovolemic
(b) Septic
(c) Cardiogenic
(d) Anaphylactic
Answer:
(a) Hypovolemic
Rationale:
The most common form of shock is hypo-volemic, accounting for more than one-third of all ED visits related to shock. Septic is the next most common form of shock.
Question 3.
Which of the following would be an early set of symptoms of toxic shock syndrome?
(a) Nausea, vomiting, diarrhea, and fever
(b) Hypotension, tachycardia, and cyanosis
(c) Scant urine output, hypertension, and rash
(d) Disorientation, hypertension, and shivering
Answer:
(a) Nausea, vomiting, diarrhea, and fever
Rationale:
Nausea, vomiting, diarrhea, and fever are - often the early signs of toxic shock because it often mimics flu-like symptoms. Hypotension, tachycardia, rash, disorientation, and scant urine are often later symptoms seen in toxic shock. Hypertension is not seen in this condition.
Question 4.
Which of the following is the main cause of death from a major burn injury during the first 24 hours?
(a) Infectious processes
(b) Acute Respiratory Distress Syndrome (ARDS)
(c) Hypovolemic shock
(d) Systemic Inflammatory Response Syndrome (SIRS)
Answer:
(c) Hypovolemic shock
Rationale:
The main cause of death from a major burn injury during the first 24 hours is hypovolemic shock. While losing capillary membrane permeability, the patient begins to third space and the intravascular volume is quickly depleted. Infection is most likely to develop after 24 to 36 hours. ARDS and SIRS are multisystem complications that may develop a few days after the initial injury.
Question 5.
During an insertion, a supine, hypovolemic patient has a syncopal episode. Assuring the patient is breathing and has a palpable pulse, the next response should be to:
(a) complete the IV insertion and recheck the ABCs.
(b) use spirits of ammonia to awaken the patient.
(c) abort the IV insertion and move the patient to a cardiac room.
(d) obtain a stat ECG and draw cardiac enzymes.
Answer:
(a) complete the IV insertion and recheck the ABCs.
Rationale:
In this situation, complete the intravenous needle insertion and recheck the ABCs. After assuring that the ABCs are intact, the most helpful intervention would be to initiate IV fluids; thus, the intravenous line must be started. The patient is already supine. Another team member could elevate the legs, but the line is imperative. The patient has most likely experienced a vasovagal response. Spirits of ammonia might be an option, but the IV line is the higher priority. The patient does not need to be placed in a different room; and unless the patient manifests other symptomatology that makes the nurse concerned about a cardiac problem, the electrocardiogram and cardiac enzymes would not be necessary.
Question 6.
Which of the following is the most common pathophysiologic mechanism in anaphylactic shock?
(a) Increased intracranial pressure
(b) Increased arterial pressure
(c) Decreased cardiac output
(d) Massive peripheral vasodilation
Answer:
(d) Massive peripheral vasodilation
Rationale:
Massive peripheral vasodilation is the most common pathophysiologic mechanism in anaphylactic shock. Histamine and other biochemicals cause an increase in capillary membrane permeability, which results in the massive vasodilation. This causes red, flushed skin and tissue swelling. Intracranial pressure is not immediately affected. Arterial pressure is decreased and cardiac output may actually initially be increased because of the body’s response to the antigen.
Question 7.
The most common physiologic mechanism in cardiogenic shock is:
(a) increased cardiac output.
(b) decreased cardiac output.
(c) peripheral vasodilation.
(d) increased preload.
Answer:
(b) decreased cardiac output.
Rationale:
The most common physiologic mechanism in cardiogenic shock is decreased cardiac output. Peripheral vasodilation may occur, but it is not the primary causative mechanism. Depending on the cause, the preload is increased, the afterload is decreased, and myocardial contractility is impaired.
Question 8.
The most common complications of shock include all of the following EXCEPT:
(a) acute renal failure.
(b) disseminated intravascular coagulation (DIC).
(c) acute respiratory distress syndrome (ARDS).
(d) compartment syndrome.
Answer:
(d) compartment syndrome.
Rationale:
Compartment syndrome is NOT a common complication of shock. This is an event that occurs usually due to an orthopedic event such as crush injury, a fracture (the most common cause of compartment syndrome), bums, bites, or frostbite. It can cause grave consequences for the extremity involved. Abdominal compartment syndrome can also occur, but it is not as frequent and is not a complication of shock. Even though a patient may only be in shock for a short amount of time, serious multisystem complications may develop from this brief period of tissue hypoperfusion such as acute renal failure, disseminated intravascular coagulation, and acute respiratory distress syndrome.
Question 9.
Which of the following diagnostic indicators would be most helpful in the diagnosis of cardiogenic shock?
(a) Positive ventilation-perfusion scan
(b) Negative Focused Assessment with Sonography for Trauma (FAST) examination
(c) Ejection fraction decrease of 20% noted on echocardiogram
(d) Hemoglobin decrease of 10 g/dL
Answer:
(c) Ejection fraction decrease of 20% noted on echocardiogram
Rationale:
An ejection fraction (EF) decrease of 20% would be the best diagnostic indicator in the diagnosis of cardiogenic shock. An EF of 55% or higher is considered normal. A decreased EF is seen in cardiogenic shock as well as in congestive heart failure and in some cardiomyopathies. A positive V/Q scan is diagnostic for a pulmonary embolus. A negative FAST examination would not be indicated because it is used to identify blood in the abdomen and a hemoglobin decrease to 10 g/dL would be indicative of hemorrhagic shock.
Question 10.
An elderly patient presents in the ED after a fall down a flight of steps at home. The patient is alert, a cervical spinal injury is ruled out, and the patient is currently being evaluated for further trauma.
Vital signs for this patient are as follows:
Blood pressure—88/48 mm Hg
Pulse—64 beats/minute
Respirations—18 breaths/minute
Temperature—98.2° F (36.8° C)
Pulse oximetry—94% on room air
An intravenous fluid bolus of 500 mL has been administered for hypotension. Which of the following current medications that the patient is receiving would explain the slow heart rate?
(a) Proton-pump inhibitor
(b) Beta-blocker
(c) Anticoagulant
(d) Antidepressant
Answer:
(b) Beta-blocker
Rationale:
Beta-blockers will mute the normal tachy-cardic response initially seen in hypovolemia. This is an important consideration to keep in mind because many patients are on these medications, often puzzling the most experienced clinicians. Proton pump inhibitors, anticoagulants, and antidepressants usually do not affect the heart rate.
Question 11.
An unrestrained patient is brought to the emergency department after a motor vehicle crash. He is alert and oriented with the following vital signs:
Blood pressure—88/40 mm Hg Pulse—42 beats/minute Respirations—22 breaths/minute Pulse oximetry—95 % on room air Temperature—99.2° F (37.3° C)
This is most likely due to which of the following types of shock?
(a) Hypovolemic
(b) Neurogenic
(c) Anaphylactic
(d) Septic
Answer:
(b) Neurogenic
Rationale:
The hallmark of neurogenic shock is bradycardia. This occurs because of the loss of sympathetic responses. The parasympathetic system is in control. The vagal response associated with this system is bradycardia. Hypovolemic, anaphylactic, and septic types of shock all have tachycardia as a predominant symptom.
Question 12.
Septic shock in a pediatric patient often has which of the following associated clinical assessment findings?
(a) Projectile vomiting
(b) Pulmonary edema
(c) Petechial rash
(d) Jugular venous distension
Answer:
(c) Petechial rash
Rationale:
Sepsis in a pediatric patient is often accompanied by a petechial rash, usually secondary to an overwhelming infectious process, such as meningococ- cemia. Projectile vomiting may be a sign of increased intracranial pressure. Pulmonary edema and jugular venous distension are associated with cardiogenic shock.
Question 13.
Which of the following is the most common cause of cardiogenic shock?
(a) Septal wall rupture
(b) Valve dysfunction
(c) Infective endocarditis
(d) Left ventricular failure
Answer:
(d) Left ventricular failure
Rationale:
Left ventricular failure is the most common cause of cardiogenic shock, often the result of a myocardial infarction with the loss of greater than 40% muscle mass. Septal wall rupture, acute valve dysfunction, and complications from infective endocarditis can also contribute to cardiogenic shock, but left ventricular failure is the hallmark.
Question 14.
Which of the following is the pathophysiologic basis for all forms of cardiogenic shock?
(a) Decreased cardiac output
(b) Increased cardiac output
(c) Decreased preload
(d) Mitral regurgitation
Answer:
(a) Decreased cardiac output
Rationale:
Decreased cardiac output is the pathophysiological basis for all forms of cardiogenic shock. This is due to the heart’s inability to meet the normal metabolic demands. Both the preload and afterload are increased along with the pulmonary artery pressures. However, the overall cardiac output and blood pressure is significantly decreased. Mitral regurgitation can be an etiology of cardiogenic shock, but it is not the overall pathophysiologic basis.
Question 15.
The pathophysiologic syndrome of shock causes abnormal metabolic changes and an increase in which of the following?
(a) Oxygen saturation
(b) Glucose
(c) Thrombocytes
(d) Lactic acid
Answer:
(d) Lactic acid
Rationale:
The syndrome of shock slows down metabolic processes, causing an increase in lactic acid levels. Lactic acid, an end product of anaerobic metabolism, contributes to peripheral vasodilation, hypotension, and decreased organ perfusion. Oxygen saturation may be decreased as a result of the lactic acid levels. Thrombocytes are generally not affected unless the shock results in disseminated intravascular coagulation (DIC).
Question 16.
Which of the following are the earliest signs of hypovolemic shock?
(a) Tachycardia, restlessness, and thirst
(b) Hypoxia, dysrhythmias, and tremors
(c) Hypotension, flushed extremities, and anxiety
(d) Oliguria, cyanosis, and confusion
Answer:
(a) Tachycardia, restlessness, and thirst
Rationale:
Tachycardia, restlessness, and thirst are often seen early in hypovolemic shock. Tachycardia is due to increased epinephrine secretion in response to a decreased preload. Restlessness can occur from the epinephrine secretion as well as hypoxemia. Thirst is due to decreased extracellular fluid in mucous membranes as” it is being shunted back to core circulation. This epinephrine secretion is due to the compensatory effects of the “fight-or-flight” response. The other manifestations would occur in later phases.
Question 17.
Which of the following would a patient in septic shock most likely demonstrate?
(a) Respiratory acidosis
(b) Respiratory alkalosis
(c) Metabolic acidosis
(d) Metabolic alkalosis
Answer:
(c) Metabolic acidosis
Rationale:
The most common acid-base disturbance in septic shock is metabolic acidosis. Without treatment, metabolic acidosis will become progressively worse; steps need to be taken to bring the patient into a compensatory mode to recovery. Treatment of metabolic acidosis is variable depending on the cause, the degree of acidity, and whether it is acute or chronic. In severe metabolic acidosis, intravenous sodium bicarbonate is sometimes used. If the problem is fixed, the body will regulate itself back to a normal pH; however, there are times when sodium bicarbonate is rlecessary, especially if the pH is at the 7.0 to 7.1 level.
Question 18.
Which of the following assessment findings indicates that the compensatory response mechanisms for shock are failing?
(a) Cool, clammy skin
(b) Pale, moist skin
(c) Rapid capillary refill time
(d) Mottled, cold skin
Answer:
(d) Mottled, cold skin
Rationale:
Mottled, cold skin indicates an often irre¬versible state of shock and is often accompanied by multisystem organ failure. Cool, clammy, and moist skin are all indicative of shock, but they are also evidence of the compensatory effects working, causing vasoconstric¬tive reactions throughout the body. A rapid capillary refill time would be a positive normal response.
Question 19.
Which of the following is NOT a clinical symptom of cardiogenic shock?
(a) Pulmonary edema
(b) Jugular venous distension
(c) Low central venous pressure
(d) Hypotension
Answer:
(c) Low central venous pressure
Rationale:
Cardiogenic shock exhibits a high central venous (right atrial) pressure, not low. Pulmonary edema, jugular venous distension, and hypotension are manifestations of cardiogenic shock, which are all the result of decreased cardiac output.
Question 20.
Which of the following is the primary reason to use vasopressors in the treatment of cardiogenic shock?
(a) Increase heart rate
(b) Improve tissue perfusion
(c) Decrease myocardial contractility
(d) Promote vasodilation
Answer:
(b) Improve tissue perfusion
Rationale:
Vasopressors are used in cardiogenic shock to improve tissue perfusion. Depending on the type, vasopressors are used to increase peripheral vasoconstriction and thereby increase major organ and tissue perfusion. Tachycardia is often a side effect of vasopressors and needs to be monitored closely. They would not be used to decrease contractility or promote vasodilation, which are both negative responses.
Question 21.
Which of the following is the first priority when beginning treatment for a patient in septic shock?
(a) Oxygen delivery and intravenous access
(b) Orthostatic vital signs and temperature
(c) Complete blood count and lactic acid levels
(d) Intravenous fluid bolus and dopamine infusion
Answer:
(a) Oxygen delivery and intravenous access
Rationale:
Oxygen delivery and volume replacement are the main priorities in beginning to treat a patient in septic shock. Fluid replacement will allow oxygen and nutrients to perfuse impaired tissues and organs in sep¬tic shock. OSVS and temperatures are often unreliable in assessing for septic shock. A complete blood count (CBC) and lactic acid levels will be performed, but the priorities are oxygenation and intravenous access. Dopamine may be started, but the intravenous access must be present to utilize it or other pressor agents as well as the fluid bolus.
Question 22.
Which of the following is NOT an initial symptom of anaphylactic shock?
(a) Bronchospasm
(b) Expiratory wheezing
(c) Tachycardia
(d) Hyperthermia
Answer:
(d) Hyperthermia
Rationale:
Hyperthermia is usually not associated with anaphylactic shock. Although the skin is flushed and warm, a rise in actual temperature does not occur. Bron- chospasm, expiratory wheezing, and tachycardia are all classic signs of anaphylactic shock, along with anxiety, hypotension, and peripheral edema.
Question 23.
Which of the following is the antibody/antigen primarily associated with anaphylactic shock?
(a) IgM
(b) IgG
(c) IgA
(d) IgE
Answer:
(d) IgE
Rationale:
The mechanism of anaphylaxis is mediated primarily by antibodies specifically those of the immunoglobulin E (IgE) class. These antibodies recognize the offending antigen and bind to it. The IgE antibodies also bind to specialized receptor molecules on mast cells and basophils, causing these cells to release their stores of inflammatory chemicals such as histamine, serotonin, and leukotrienes, which have a number of effects, including constriction of the smooth muscles, which leads to breathing difficulty; dilation of blood vessels, causing skin flushing and hives; and an increase in vascular permeability, resulting in edema and hypotension. IgM is an immunoglobulin that helps protect the body from new bacterial invasions. IgG is an antibody that responds to organisms that have invaded the body before. They have a “memory.” IgA antibodies are located in mucous membranes found in the lungs, intestines, stomach, and sinus areas and work in the immune system of these mucous membranes. They are present in saliva, blood, and tears.
Question 24.
Initial fluid resuscitation for a multiple trauma patient in hypovolemic shock should include which of the following?
(a) Crystalloid infusion
(b) Colloid infusion
(c) Dopamine infusion
(d) Hypertonic infusion
Answer:
(a) Crystalloid infusion
Rationale:
Two large-bore IVs with infusion of 2 L of normal saline or lactated ringer’s is the standard treatment for a multiple trauma patient in hypovolemic shock. Either is accepted now. Colloid infusions can be acceptable, but they are not the first-line fluid of choice. Dopamine may be utilized for renal perfusion after initial fluid resuscitation measures are completed. Hypertonic fluids such as 3 % and 5 % saline have been suggested, but further trials and studies need to be completed.
Question 25.
All of the following are etiologies for hypovolemic shock EXCEPT:
(a) abdominal trauma.
(b) femoral fractures.
(c) fatty emboli.
(d) dissecting aortic aneurysm.
Answer:
(c) fatty emboli.
Rationale:
Hypovolemic shock may often be seen in internal bleeding from abdominal trauma, femoral fractures, and dissecting aortic aneurysm. The chest, abdomen, pelvis, and femur areas can accommodate several units of blood and should be assessed for in occult bleeding. Fatty emboli are not associated with hypovolemic shock.
Question 26.
A patient in hypovolemic shock who is concurrently taking a beta-blocker would most likely have which set of basic vital signs?
(a) Blood pressure—128/70 mm Hg; pulse: 74 beats/ minute
(b) Blood pressure—88/50 mm Hg; pulse: 68 beats/ minute
(c) Blood pressure—84/58 mm Hg; pulse: 130 beats/ minute
(d) Blood pressure—166/104 mm Hg; pulse: 62 beats/ minute
Answer:
(b) Blood pressure—88/50 mm Hg; pulse: 68 beats/ minute
Rationale:
Beta-blocker medications will mute the normal tachycardic response to hypovolemic shock. A blood pressure of 88/50 with a pulse of 68 demonstrates this effect of beta-blocker activity in a shock situation. This can often be a missed assessment point when hypotension is present, but tachycardia is absent, giving the clinician a false sense of reassurance. Owing to the beta-blocker, the body is not able to compensate by increasing the heart rate, which can compound the shock state. A blood pressure of 128/70 and a pulse rate of 74 are normal vital signs. A blood pressure of 84/58 with a heart rate of 130 would be a normal variation that would be experienced by a patient not on beta-blocker medications. A blood pressure of 166/104 with a heart rate of 62 would not represent a shock state because this patient is not hypotensive or tachycardic.
Question 27.
After diagnosis and aggressive treatment of septic shock, which of the following are key indicators of continued clinical improvement?
(a) Tachycardia and confusion
(b) Hypotension with vasopressor support
(c) Hypertension and lactic acidosis
(d) Normotension and tachycardia
Answer:
(d) Normotension and tachycardia
Rationale:
Normotension and tachycardia are signs of clinical improvement in a patient with septic shock.
The elevated heart rate is in response to the infection and is being tolerated as evidence by the normal blood pressure. Confusion, hypotension while receiving vasopressor support, hypertension, and the presence of lactic acidosis would not be indicators of positive improvements for the patient.
Question 28.
Which of the following is NOT a normal physiologic compensatory mechanism in hypovolemic shock?
(a) Baroreceptors interpret decreased blood flow, which stimulates the pulse to increase.
(b) Antidiuretic hormone secretion is increased.
(c) Epinephrine secretion stimulates peripheral vasoconstriction.
(d) Endotoxin circulation causes hyperthermia.
Answer:
(d) Endotoxin circulation causes hyperthermia.
Rationale:
Endotoxin circulation is associated with septic shock, not hypovolemic shock. In hypovolemic shock, the body compensates for the shock state by increasing the heart rate through sympathetic stimulation, one of which occurs through the baroreceptor response, secreting antidiuretic hormone for water and sodium up-take to keep fluid within the body, and epinephrine secretion to facilitate peripheral vasoconstriction.
Question 29.
Which of the following is NOT an early goal-directed therapy for septic shock?
(a) Quick screening for the potential for sepsis
(b) Identification of septic symptomology
(c) Starting antibiotic therapy before obtaining cultures
(d) IV fluid boluses in rapid succession if tolerated
Answer:
(c) Starting antibiotic therapy before obtaining cultures
Rationale:
Although treatment should not be delayed, cultures should be quickly obtained before starting antibiotic therapy. Quick screening and identification of symptoms are crucial in the initial diagnosis of sepsis. Once the potential for sepsis is identified, fluid boluses are indicated if concurrent hypotension is present.
Question 30.
The use of intravenous steroids in the patient with septic shock will allow for which of the following effects?
(a) Lower blood glucose levels
(b) Decrease systemic effects of inflammation
(c) Prevent the development of thromboemboli
(d) Increase vasoconstriction
Answer:
(b) Decrease systemic effects of inflammation
Rationale:
The use of steroids in septic shock is primarily to decrease the systemic effects of inflammation. Although their use may be controversial in other situations, the anti-inflammatory effects of the steroids, in conjunction with other forms of aggressive treatment, are standard in the treatment of septic shock. Steroid administration will not lower blood glucose (on the contrary, steroids will increase blood glucose levels), prevent thromboembolic disease, or increase the likelihood of vasoconstriction.
Question 31.
A multiple trauma patient in hypovolemic shock has received 2 L of intravenous normal saline. He continues to be hypotensive and tachycardic. Which of the following is NOT an appropriate action at this time?
(a) Reassess for other potential areas of bleeding.
(b) Start high-dose intravenous vasopressors.
(c) Continue fluid resuscitation while monitoring the patient.
(d) Consider infusing blood products.
Answer:
(b) Start high-dose intravenous vasopressors.
Rationale:
High-dose vasopressors are not indicated in the treatment of hypovolemic shock. This patient may require more fluids and/or blood products. The patient may continue to be symptomatic because of occult bleeding sites not yet identified.
Question 32.
Which of the following is the leading cause of death in the first 24 hours of a major burn injury?
(a) Hypovolemia
(b) Fluid overload
(c) Infection/sepsis
(d) Multisystem organ failure
Answer:
(a) Hypovolemia
Rationale:
The leading cause of death during the first 24 hours after a major burn injury is hypovolemia.
As a result of the burn injury, third spacing begins to occur causing a dramatic decrease in intravascular volume and perfusion. After 24 to 48 hours, infection, sepsis, and major organ failure are more likely to be contributing factors in the cause of death.
Question 33.
Which of the following is NOT a common complication of shock?
(a) Disseminated intravascular coagulation (DIC)
(b) Multiple pulmonary emboli
(c) Acute respiratory distress syndrome (ARDS)
(d) Acute renal failure (ARF)
Answer:
(b) Multiple pulmonary emboli
Rationale:
Multiple pulmonary emboli are not common complications of shock. Disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), and acute renal failure (ARF) are all common complications of shock and are the result of prolonged impaired perfusion.
Question 34.
Which of the following is NOT an etiology of cardiogenic shock?
(a) Cardiac tamponade
(b) Hyponatremia
(c) Beta-blocker overdose
(d) Ventricular tachycardia
Answer:
(b) Hyponatremia
Rationale:
Hyponatremia is not a known factor in the development of cardiogenic shock. Cardiac tamponade (blood in the pericardial space) impairs the myocardial ability to pump, leading to a shock state. A beta-blocker overdose and dysrhythmias such as ventricular tachycardia will dramatically suppress cardiac output and predispose the patient to shock.
Question 35.
Which of the following is the drug of choice for the treatment of cardiogenic shock?
(a) Dopamine (Intropin)
(b) Dobutamine (Dobutrex)
(c) Nitroglycerin (Trinitrate)
(d) Vasopressin
Answer:
(b) Dobutamine (Dobutrex)
Rationale:
Dobutamine is a potent vasopressor but has less of a tendency to increase the heart rate as opposed to dopamine. Tachycardia is a dangerous side effect of dopamine, and can worsen cardiogenic shock because of the increased myocardial demands. Therefore, dobutamine is the preferred drug for cardiogenic shock. Vasopressin is used to treat hypotension in patients who are suffering from a vasodilatory type of shock. It is used for these patients after there is no response from fluid boluses and catecholamine infusions. Nitroglycerin is a nitrate utilized in the treatment of renal failure and angina and congestive heart failure with a myocardial infarction. Nitroglycerin would bring blood pressures down because of its vasodilatory effects. It would be contraindicated in hypotension.
Question 36.
Which of the following statements best describes the pathophysiology behind neurogenic shock? Neurogenic shock is caused by a massive vasodilation from:
(a) suppression of the sympathetic nervous system.
(b) increased intracranial pressure.
(c) the release of histamine.
(d) the systemic inflammatory process.
Answer:
(a) suppression of the sympathetic nervous system.
Rationale:
Neurogenic shock is caused by a massive vaso¬dilation from impaired function of the sympathetic ner¬vous system. Without the sympathetic nervous system, the vasculature responds only to the parasympathetic nervous system and, therefore, vasodilates. In neurogenic shock, the intracranial pressure is unaffected. Although both are forms of distributive shock, the vasodilation from histamine release occurs in anaphylactic shock and vasodi¬lation in the inflammatory processes occurs in septic shock.
Question 37.
A 60-year-old male is admitted to the emergency department from home for a syncopal episode after having frequent, large amounts of dark red bloody stools this morning. He is 1-week postoperative following a total right hip replacement. He is awake and somewhat confused. His skin is pale and diaphoretic. His vital signs are as follows:
Blood pressure—80/62 mm Hg
Pulse—136 beats/minute
Respirations—26 breaths/minute
Temperature—96.8° F (36° C) (orally)
Pulse oximetry—95 % on room air
Which of the following is the priority intervention for this patient?
(a) Prepare for emergency endoscopy with surgery on standby.
(b) Assist with endotracheal intubation and assist respirations as needed.
(c) Draw labs for type and crossmatch and initiate two large-bore intravenous lines.
(d) Discuss end-of-life care wishes with both the patient and family.
Answer:
(c) Draw labs for type and crossmatch and initiate two large-bore intravenous lines.
Rationale:
This patient is obviously bleeding and is in apparent profound hypovolemic shock. The number one priority for this patient is two large-bore intravenous (IV) lines and lab studies including a type and crossmatch. Labs should be drawn as the IV lines are initiated. Intubation and end-of-life issues are not currently applicable in this situation. Endoscopy may be indicated once the patient is stabilized.
Question 38.
Assessment of an unrestrained patient from a motor vehicle crash reveals hypotension; warm, dry skin; and bradycardia. Which of the following is the most likely cause?
(a) Cardiogenic shock
(b) Neurogenic shock
(c) Hypovolemic shock
(d) Septic shock
Answer:
(b) Neurogenic shock
Rationale:
Bradycardia is the hallmark symptom of neurogenic shock. Spinal trauma, from a motor vehicle crash, may cause an interruption in the sympathetic nervous system integrity. Although the patient may be hypotensive, the skin is often warm and dry in neurogenic shock. Hypovolemic, septic, and cardiogenic shock would most likely have tachycardia, hypotension, and cool, moist skin.
Question 39.
Which of the following symptoms would be indicative of the compensatory stage in hypovolemic shock?
(a) Narrowing pulse pressure
(b) Severe hypotension
(c) Increasing lactic acid level
(d) Increasing urine output
Answer:
(d) Increasing urine output
Rationale:
Increasing urine output indicates that renal perfusion is maintained and is a sign of compensated hypovolemic shock. A narrowing pulse pressure, severe hypotension, and increased lactic acid levels are indicative of uncompensated forms of shock.
Question 40.
A patient with pancreatitis is at risk for which of the following two types of shock?
(a) Hypovolemic and Neurogenic
(b) Septic and Anaphylactic
(c) Cardiogenic and Anaphylactic
(d) Hypovolemic and Septic
Answer:
(d) Hypovolemic and Septic
Rationale:
A patient with pancreatitis is especially prone to both hypovolemic and septic shock. Severe dehydration from vomiting and diarrhea is often seen in pancreatitis, leading to hypovolemia. Pancreatitis can also be hemorrhagic. When this type is present, there is a risk of hypovolemic shock. The inflammatory process associated with pancreatitis and exacerbated by the hypovolemia can lead to sepsis. Patients with pancreatitis are not at high risk for cardiogenic, neurogenic, or anaphylactic shock (unless they were to react to antibiotics given for septic shock!).
Question 41.
Which of the following is the end result of the activation of the renin-angiotensin-aldosterone system in shock situations?
(a) Increased vascular volume
(b) Increased urinary output
(c) Generalized vasodilation
(d) Release of norepinephrine
Answer:
(a) Increased vascular volume
Rationale:
The renin-angiotensin-aldosterone system is activated when decreased extracellular fluid and hypotension is present. The end result is the reabsorption of sodium and water in the body, which causes an increase in vascular volume. In shock, the body needs to reserve as much water as it can and keep it in the intra-vascular system. It also causes vasoconstriction from the release of aldosterone in the process. It does not release norepinephrine. Urinary output is reduced and therefore concentrated. If fluid is retained in the body, the urinary output would decrease.
Question 42.
A husband brings his wife to the emergency department for sudden respiratory distress that occurred immediately after eating seafood. She is nonresponsive, her face is flushed, and her lips and tongue have marked swelling. Her blood pressure is 80/42 mm Hg and her pulse is 120 beats/minute. Which of the following should be administered first?
(a) Methylprednisolone (Solu-Medrol)
(b) Epinephrine (Adrenalin)
(c) Normal saline IV fluid bolus
(d) Diphenhydramine (Benadryl)
Answer:
(b) Epinephrine (Adrenalin)
Rationale:
Epinephrine (Adrenalin) is the drug of choice for anaphylaxis and impending anaphylactic shock. This is often followed by IV fluids, an antihistamine such as diphenhydramine (Benadryl), and a steroid dose such as methylprednisolone (Solu-Medrol). Return of symptoms can occur later, which is known as biphasic anaphylaxis.
Question 43.
All of the following patient past histories are at increased risk for hypovolemic shock EXCEPT:
(a) diabetic ketoacidosis.
(b) diabetes insipidus.
(c) diuretic overuse.
(d) digitalis toxicity.
Answer:
(d) digitalis toxicity.
Rationale:
Digitalis toxicity is not a contributing factor in hypovolemic shock. Diabetic ketoacidosis, diabetes insipidus (lack of antidiuretic hormone), and diuretic overuse all can contribute to the development of severe dehydration and hypovolemic shock.
Question 44.
The presence of a hemorrhagic shock-like state will initiate which of the following physiologic compensatory mechanisms?
(a) Decreased secretion of antidiuretic hormone (ADH)
(b) Increased secretion of antidiuretic hormone (ADH)
(c) Decreased secretion of epinephrine
(d) Decreased secretion of norepinephrine
Answer:
(b) Increased secretion of antidiuretic hormone (ADH)
Rationale:
A hemorrhagic shock state will cause an increased secretion of antidiuretic hormone (ADH). ADH helps restore lost fluid volume by increasing the uptake of sodium and water. There will be a decreased urine output, which is the desired compensatory effect in shock. Epinephrine and norepinephrine are released because of the sympathetic nervous system stimulation to compensate for the shock state.
Question 45.
A large pulmonary embolus is most likely to cause which of the following types of shock?
(a) Hypovolemic shock
(b) Distributive shock
(c) Obstructive shock
(d) Neurogenic shock
Answer:
(c) Obstructive shock
Rationale:
A large pulmonary embolus can obstruct outflow of blood from the heart and lungs, thereby causing an obstructive form of shock. Other causes of obstructive shock include cardiac tamponade and a gravid uterus lying on the inferior vena cava.
Question 46.
On the basis of their predisposition, which of the following patients is most at risk for the development of septic shock?
(a) A 40-year-old black male with a history of hypertension
(b) A 50-year-old perimenopausal, white female with a history of GERD
(c) A 30-year-old white male with a white blood cell count of 1,000 per microliter
(d) A 60-year-old Hispanic female on anticoagulants
Answer:
(c) A 30-year-old white male with a white blood cell count of 1,000 per microliter
Rationale:
Immunosuppressed patients are at significant risk for the development of septic shock. Steroids, chemotherapy, radiation therapy, HIV-positive status, splenectomy, and stress contribute to immunosuppression. Hypertension, gastroesophageal reflux disease, and anticoagulant therapy do not predispose patients to sepsis.
Question 47.
Which of the following symptoms is of most concern in an 84-year-old female regarding responses to potential shock states?
(a) Syncopal episodes upon getting out of bed
(b) Brief tachycardia upon physical exertion
(c) Urine output of 30 mL over the past hour
(d) Extremities cool and dry to the touch
Answer:
(a) Syncopal episodes upon getting out of bed
Rationale:
Syncopal episodes in an elderly patient can be life-threatening. Elderly patients may have unique symptoms of shock, so the patient would need to be quickly assessed for orthostatic hypotension, cardiac dysrhythmias, or hypovolemia from dehydration as the cause for the syncope. All of these can make the elderly patient at risk for falls, which can contribute to other catastrophic events for this age group. Tachycardia after exertion and urine output of 30 mL/hour are normal parameters. Cool extremities that are dry to touch would not raise a red flag for this patient.
Question 48.
Which of the following is the first priority emergency intervention for the treatment of all forms of shock?
(a) Rapid infusion of intravenous fluids
(b) Initiation of vasopressors
(c) Administration of high-flow oxygen
(d) Airway assessment and maintenance
Answer:
(d) Airway assessment and maintenance
Rationale:
Airway assessment and maintenance is always the number one priority in the care of a patient in shock. Administration of intravenous fluids, oxygen, or vasopressors will not do any good in the treatment of shock if the airway is not assessed and maintained. If the patient does not have a patent airway, no other interventions will matter.
Question 49.
A 5-year-old has been brought to the emergency department by her parents who state she has had persistent vomiting and diarrhea for the past 24 hours.
Her general appearance shows she is awake but drowsy. Her color is pale, but her skin is warm and dry. Her weight shows a decrease from her previous weight of 45 lb (20.4 kg) to 42 lb (19 kg). She has no prior medical history. Vital signs are as follows:
Blood pressure—72/64 mm Hg ;
Pulse—140 beats/minute
Respirations—28 breaths/minute
Pulse oximetry—98 % on room air
Temperature—100.4° F (38° C), rectally
Which of the following would be the correct amount of intravenous fluids to infuse as the initial bolus?
(a) 190 mL
(b) 380 mL
(c) 420 mL
(d) 840 mL
Answer:
(b) 380 mL
Rationale:
The standard intravenous fluid dose for pediatric patients is 20 mL/kg. Since this child now weighs 19 kg, multiply 19 times the 20 ml. The correct bolus; dose is 380 ml. The amount used for fluid resuscitation in a neonate is 10 mL/kg and may be used in children with cardiac histories. This child had no prior medical history. When calculating the dosage for the bolus, be sure to change the pounds to kilograms. This is the most common mistake that is made.
Question 50.
Which of the following is the most common form of distributive shock?
(a) Anaphylactic
(b) Neurogenic
(c) Septic
(d) Cardiogenic
Answer:
(c) Septic
Rationale:
Septic shock is the most common form of distributive shock. Distributive shock is caused by a vasodilation that occurs with a subsequent loss of afterload. Anaphylactic and neurogenic shock are forms of distributive shock, but they are not as common. Cardiogenic shock is not a form of distributive shock. Cardiogenic shock occurs due to the loss of the pumping ability of the heart.
Question 51.
A patient diagnosed with an acute abdominal aortic dissection is most at risk for which of the following types of shock?
(a) Hypovolemic
(b) Neurogenic
(c) Distributive
(d) Cardiogenic
Answer:
(a) Hypovolemic
Rationale:
Hypovolemic shock is the type of shock most often associated with dissecting aortic aneurysms. As the intravascular blood volume decreases from the dis-section, the hypovolemic shock progresses until the aorta can be repaired. Many complications can ensue from this brief, catastrophic hypovolemic state when the actual rupture occurs.
Question 52.
Which of the following organs/glands is NOT part of the process when the renin-angiotensin-aldosterone system is in operation?
(a) Lungs
(b) Liver
(c) Adrenal gland
(d) Thyroid gland
Answer:
(d) Thyroid gland
Rationale:
The thyroid gland is not involved in the process of the renin-angiotensin-aldosterone system. At the forefront is the renal system that causes the release of renin. Angiotensin I is converted to angiotensin II in the lungs. Aldosterone is released from the adrenal glands. The liver is involved in the secretion of angiotensinogen.
Question 53.
Which of the following is NOT proper treatment for hypovolemic shock?
(a) Placing the patient in Trendelenburg position
(b) Oxygen delivery at 100% by non-rebreather mask
(c) Administering warmed isotonic solution
(d) Covering the patient with warm blankets
Answer:
(a) Placing the patient in Trendelenburg position
Rationale:
Trendelenburg position is not recommended in the treatment of hypovolemic shock anymore. This position has been proven to have negative effects on a patient in shock. The proper position now is “shock” position or “modified Trendelenburg,” which is to keep the body flat and elevate the feet/legs. Providing oxygen via a non-rebreather mask at high flow to maintain the pulse oximetry reading between 94% and 98% is necessary. It is important to be concerned about hyperoxia; however, in the early stages of care, it is acceptable and recommended to provide the high-flow oxygen for a period of time. Keeping the patient warm is also important because hypothermia can cause many complications including acidosis and coagulopathies. Administration of warmed isotonic fluids is important for the patient. The intravenous lines will also be necessary for possible blood products.
Question 54.
Which of the following physiologic mechanisms does NOT contribute to the development of clinical hypoperfusion in shock?
(a) Decreased venous return to the heart
(b) Onset of generalized vasodilitation
(c) Obstruction of circulating blood volume
(d) Increased peripheral vascular resistance
Answer:
(d) Increased peripheral vascular resistance
Rationale:
Peripheral vascular resistance is decreased in clinical hypoperfusion, not increased. Other factors that do contribute to the development of symptoms include decreased venous return to the heart, vasodilitation causing distributive types of shock, and an obstruction of circulating blood volume.
Question 55.
Which of the following can lead to the development of an obstructive form of shock?
(a) Cardiac dysrhythmia
(b) Tension pneumothorax
(c) Ectopic pregnancy
(d) Bacterial pneumonia
Answer:
(b) Tension pneumothorax
Rationale:
A tension pneumothorax is a major factor in the development of obstructive shock. The tension pneumothorax causes a gradual compression on the mediastinum, including the heart and great vessels, which obstructs the venous return and impairs contractility. A cardiac dysrhythmia may lead to cardiogenic shock. Ectopic pregnancies are associated with hypovolemic shock. Bacterial pneumonia can progress to septic shock.
Question 56.
A dopamine (Intropin) infusion has been ordered for a patient in cardiogenic shock. Which of the following is NOT a precaution for the use of this medication?
(a) Close observations for the development of tachydysrhythmias
(b) Using a patent central line for drug administration
(c) Regular measurements to check for QRS complex prolongation
(d) Frequent monitoring of vital signs and urine output
Answer:
(c) Regular measurements to check for QRS complex prolongation
Rationale:
Dopamine (Intropin) does not affect prolongation of the QRS complex. Dopamine can cause tachydysrhythmias, requires a central IV line for administration and frequent monitoring of vital signs and urine output. Although dopamine can be used for cardiogenic shock, dobutamine (Dobutrex) is the preferred drug because it has less of a tendency to cause tachydysrhythmias.
Question 57.
A patient in profound hemorrhagic shock is rapidly receiving multiple units of blood through the emergency department’s massive transfusion protocol. Which of the following conditions is the most common complication of this treatment?
(a) Hyperkalemia
(b) Metabolic acidosis
(c) Anaphylaxis
(d) Acute hemolytic reaction
Answer:
(a) Hyperkalemia
Rationale:
After massive transfusions, hyperkalemia is of great concern because of the potential for dysrhythmias and muscular irritability. Hyperkalemia can occur because of the breakdown of cells as blood is stored. Each unit of blood given can increase the patient’s potassium level. Consider this if the patient is already hyperkalemic before blood administration. Metabolic acidosis, anaphylaxis, and hemolytic reactions are of concern, but are less frequently a complication.
Question 58.
Which of the following patients exhibiting potential shock-like symptoms has the highest triage priority?
(a) A 94-year-old female from a nursing home who has cloudy, foul-smelling urine draining from her urinary catheter. She is awake and yelling for the nurse to get out of her kitchen. Vital signs are within normal limits.
(b) A 24-year-old man who self-administered his EpiPen 1 hour before arrival after being stung by a wasp. He is alert. Color is flushed. Vital signs are within normal limits except for a pulse rate of 110 beats/minute.
(c) A 19-year-old female with a history of vomiting for 6 hours after a night of binge drinking. She is alert. Skin is warm and dry and she is texting on her phone. Vital signs are within normal limits.
(d) An 82-year-old male with a long history of smoking is complaining of abdominal and low back pain. He is restless and pale. Vital signs are within normal limits except for blood pressure of 192/108 mm Hg and a pulse rate of 128 beats/ minute.
Answer:
(d) An 82-year-old male with a long history of smoking is complaining of abdominal and low back pain. He is restless and pale. Vital signs are within normal limits except for blood pressure of 192/108 mm Hg and a pulse rate of 128 beats/ minute.
Rationale:
The restless 82-year-old male with low back and abdominal pain, history of heavy smoking and hypertension, and tachycardia needs to be immediately assessed for an abdominal aortic aneurysm, which would place him at great risk for hypovolemic shock. His past history of heavy smoking places him at risk for these conditions and he is at the highest risk at this time. The 24-year-old with the wasp sting is stable at this time and already ha^ epinephrine on board. The 94-year-old is at risk for sepsis but is stable at this time. It would be important to determine her normal mentation to determine if today’s confusion is new or old. The 19-year-old female with a history of vomiting is also stable.
Question 59.
Orthostatic vital signs (OSVS) measurements can be an additional assessment tool for the diagnosis of dehydration and/or hypovolemic shock. Which of the following is a true statement regarding this tool?
(a) OSVS are not accurate in patients older than 65 or younger than 10.
(b) Blood pressure, pulse, and respiratory rate should be assessed with the patient lying flat, sitting; and then standing.
(c) Often inaccurate, OSVS should be used in conjunction with history, physical assessment, and other diagnostic findings
(d) Do not assess OSVS on patients who are presenting with a chief complaint of syncope or vertigo.
Answer:
(c) Often inaccurate, OSVS should be used in conjunction with history, physical assessment, and other diagnostic findings
Rationale:
OSVS are an unreliable method for assessing for fluid loss or hypovolemic shock and should be used only in conjunction with history, assessment, and other diagnostic indicators. Patients can falsely compensate while sitting, thus masking the true effects of hypovolemia. Even though this test does carry some concern for its validity, it remains an accepted test and can provide objective data for the potential diagnosis of bleeding or dehydration. It can be performed on patients of any age. Only blood pressure and pulse rate are measured for this test. It can be performed on those with syncope, but these patients should be closely monitored during the test.
Question 60.
Which of the following is NOT a late sign or symptom of systemic shock?
(a) Cyanosis
(b) Anuria
(c) Obtunded
(d) Tachycardia
Answer:
(d) Tachycardia
Rationale:
Tachycardia is often an early sign in shock because of the initial release of epinephrine and the attempt in the cardiovascular system to compensate for a decreased volume. Cyanosis, anuria, and obtunded mental status are all late signs of shock.
Question 61.
Which of the following patients is most likely to develop hypovolemic shock?
(a) A 23-year-old female with a urinary tract infection
(b) A 50-year-old female with fibromyalgia
(c) An 80-year-old male with chest pain and dyspnea
(d) A 15-year-old male with diabetic ketoacidosis
Answer:
(d) A 15-year-old male with diabetic ketoacidosis
Rationale:
Diabetic ketoacidosis, especially in a young patient, often presents after prolonged vomiting, diarrhea, and decreased oral intake, and may be accompanied by an infection and hypovolemic shock. The patient with the urinary tract infection may be at risk for sepsis. The patient with chest pain and dyspnea could develop cardiogenic shock. The patient with fibromyalgia is not at risk for a shock state. The question asked was relative to hypovolemic shock.
Question 62.
Which of the following is the primary physiologic reason for hypotension and bradycardia in neurogenic shock?
(a) Third spacing of intracellular fluid
(b) Disruption in sympathetic nervous system
(c) Hypersensitivity to allergen
(d) Left ventricular hypertrophy
Answer:
(b) Disruption in sympathetic nervous system
Rationale:
Neurogenic shock occurs when there is a disruption in the sympathetic nervous system, allowing the parasympathetic nervous system to take over, which causes hypotension and bradycardia. No other form of shock causes these connected symptoms. Third spacing of intracellular fluid leads to hypovolemia. Left ventricular hypertrophy may be a contributing factor for cardiogenic shock. A hypersensitivity reaction would involve anaphylactic shock.
Question 63.
Which of the following would indicate an improvement in a patient experiencing neurogenic shock associated with a spinal cord injury?
(a) Heart rate of 4{> beats/minute
(b) Blood pressure 'of 90/62 mm Hg
(c) Temperature of 98.6° F (37° C)
(d) Respiratory rate of 28 breaths/minute
Answer:
(c) Temperature of 98.6° F (37° C)
Rationale:
Patients with neurogenic shock associated with spinal cord injuries have difficulty maintaining their temperature control. This is known as poikilothermia. A normalized temperature would be a positive turn for a patient with this type of shock. A heart rate of 46 beats/ minute would be part of the symptomatology for neurogenic shock as would the hypotension and the rapid breathing.
Question 64.
Which of the following indicates that a family member has understood instructions and education regarding their father’s situation with cardiogenic shock?
(a) “I understand that my father needs to get to the cath lab immediately. ”
(b) “I was told that it is good that his blood pressure is so low.”
(c) “We should still be able to go on our planned cruise in 10 days.”
(d) “I heard that dad had a problem with too much oxygen getting to his cells?”
Answer:
(a) “I understand that my father needs to get to the cath lab immediately. ”
Rationale:
According to the SHOCK trial, the best possible treatment for cardiogenic shock is immediate percutaneous coronary intervention (PCI or coronary artery bypass graft (CABG). These dramatically reduce the mortality rate. It is best to provide this option within 90 minutes, but it can be performed as much as 12 hours later with good results. Thinking that the patient will be well enough to travel in 10 days is not realistic on the part of the adult child. Low blood pressures do not help perfuse the patient’s body and the problem is inadequate oxygenation of the cells, hot too much oxygen.
Question 65.
Which of the following would be a potential cause of septic shock?
(a) Pyelonephritis
(b) Diabetic ketoacidosis
(c) Cardiac tamponade
(d) Tension pneumothorax
Answer:
(a) Pyelonephritis
Rationale:
Pyelonephritis is an infectious disease and, therefore, would be the disease process most likely to cause septic shock. Diabetic ketoacidosis would most likely cause a hypovolemic type of shock because of its dehydration properties. Cardiac tamponade and tension pneumothorax are both causes of obstructive shock.
Question 66.
Which of the following interventions would NOT indicate to the ED nurse that obstructive shock symptoms have been mitigated?
(a) Successful pericardiocentesis performed
(b) A 36-week gestation patient turned to the left side
(c) 14 g cathlon inserted into second intercostal space
(d) Bilateral normal saline boluses infusing
Answer:
(d) Bilateral normal saline boluses infusing
Rationale:
Normal saline boluses would not treat an obstructive shock patient. This would be indicated in situations involving hemorrhagic or hypovolemic shock. A patient would receive a pericardiocentesis to treat a cardiac tamponade which causes obstructive shock. A pregnant patient would need to be turned to her left side to keep the gravid uterus off of the inferior vena cava, thus preventing or treating hypotension associated with obstructive shock. A needle decompression would be used to treat a tension pneumothorax, which would also cause obstructive shock.
Question 67.
A slight increase in diastolic blood pressure in early shock is due to an increase in:
(a) stroke volume.
(b) heart rate.
(c) vascular tone.
(d) renal perfusion.
Answer:
(c) vascular tone
Rationale:
Increased vascular tone in early shock will cause a slight increase in the diastolic pressure. In early shock, the heart rate and the stroke volume will increase but is not the causative factor in the change in diastolic pressure. Renal perfusion will actually decrease at a later time.
Question 68.
Which of the following explains the term “permissive hypotension” as it relates to treating a patient in hypovolemic shock?
(a) Treating hypotension only when the patient is comatose
(b) Treating hypotension to a systolic pressure of 90 mm Hg
(c) Treating hypotension only when it is associated with tachycardia
(d) Treating hypotension with aggressive fluid management
Answer:
(b) Treating hypotension to a systolic pressure of 90 mm Hg
Rationale:
Treating the hypotension to maintain a systolic pressure of 90 mm Hg is a form of permissive hypertension. As long as the MAP remains approximately 65, the patient is being perfused. Aggressive measures such as copious fluid management may actually cause the injured area to bleed more and can cause more issues such as hypothermia, as well as diluting clotting factors and hemoglobin which is the oxygen-carrying capacity. Maintaining a systolic blood pressure of 90 mm Hg is carefully managed until definitive care can be provided. It is not appropriate to wait to treat hypotension until tachycardia or unconsciousness occurs. The patient may be taking beta-blockers, which would not allow tachycardia to occur, and hypotension should be treated before the patient has a decreased mentation.
Question 69.
Which of the following describes the expected action of the pulse pressure in hypovolemic shock?
(a) Remains unchanged
(b) Widens
(c) Narrows
(d) Is unobtainable
Answer:
(c) Narrows
Rationale:
The pulse pressure in hypovolemic shock becomes narrower as the shock progresses. Pulse pressure is the difference between the systolic and diastolic measurements of the blood pressure. This change in pulse pressure is an indication that the cardiac output is declining and peripheral vascular resistance is increasing.
Question 70.
Baroreceptors, a collection of sensitive cells that monitor blood pressure and volume, are found in the:
(a) pons and medulla.
(b) aortic arch and carotid arteries.
(c) aorta and renal arteries.
(d) spleen and mesenteric artery.
Answer:
(b) aortic arch and carotid arteries.
Rationale:
Baroreceptors are located in the aortic arch and carotid arteries. In a shock-like state, these sensitive cells can detect even the slightest decrease in pressure or volume and quickly send messages to the medulla. The medulla sets into motion a series of compensatory mechanisms for the body to address the shock. Responses to this include the release of epinephrine, which increases heart rate and peripheral vasoconstriction in an effort to increase the blood pressure.
Question 71.
Which of the following findings would most likely indicate obstructive shock rather than hypovolemic shock?
(a) Neck vein distension
(b) Widening pulse pressure
(c) Orthostatic hypotension
(d) Reflex tachycardia
Answer:
(a) Neck vein distension
Rationale:
Neck vein distension is often seen in conditions that cause obstructive shock. These include cardiac tamponade, tension pneumothorax, and pulmonary embolism. A widening pulse pressure is seen in increased intracranial pressure. Orthostatic hypotension can be seen in dehydration, hypovolemic shock, vasodilator therapy, and diuretic overuse. Reflex tachycardia can occur when there is a sudden change in blood volume, with orthostatic hypotension being one of the major causes.
Question 72.
Which of the following would indicate a potential shock situation in a 3-year-old pediatric patient?
(a) Blood pressure of 92/60 mm Hg
(b) Pulse rate of 110 beats/minute
(c) Responsive to painful stimuli only
(d) Responsive to verbal stimuli
Answer:
(c) Responsive to painful stimuli only
Rationale:
A child who is responsive to painful stimuli only or demonstrates lethargy is a potential candidate for the diagnosis of shock. A blood pressure of 92/60 in a 3-year-old is not hypotensive. The pulse rate of 110 beats/minute is also not indicative of gross tachycardia in this patient. Responding to verbal stimuli would be a good response.
Question 73.
Outcomes for septic shock will be most effective when which of the following guidelines are followed?
(a) Withholding antibiotic therapy until cultures are obtained
(b) Determining sepsis diagnosis after culture results
(c) Early implementation of diuretic therapy
(d) Aggressive intravenous fluid management
Answer:
(d) Aggressive intravenous fluid management
Rationale:
Aggressive fluid management is a major factor in the effective treatment of septic shock. Although initial blood cultures can be obtained while initiating treatment, antibiotics should never be held for any period of time to obtain cultures. Sepsis can be readily identified before any culture results are obtained. Diuretics would be counterproductive in a shock state.
Question 74.
Trendelenburg position in the treatment of shock is contraindicated because of all of the following EXCEPT.
(a) increased intracranial pressure.
(b) increased venous return.
(c) increased abdominal organ ischemia.
(d) increased diaphragmatic pressure.
Answer:
(b) increased venous return.
Rationale:
Trendelenburg position’s only benefit is that it increases venous return. It is not recommended for patients in shock. The negative effects are an increase in intracranial pressure, increased abdominal organ ischemia, and increased diaphragmatic pressure causing a decrease in tidal volume and an eventual decrease in respirations and oxygen perfusion.
Question 75.
Treatment of hypovolemic shock is considered successful when which of the following changes are evident?
(a) Capillary refill is 4 seconds.
(b) Urine output is at least 20 mL/hour for 4 hours.
(c) Electrocardiogram changes resolve.
(d) Systolic blood pressure is greater than 90 mm Hg.
Answer:
(d) Systolic blood pressure is greater than 90 mm Hg.
Rationale:
The treatment of hypovolemic shock is considered effective when the systolic blood pressure is at least 90 mm Hg. This is in conjunction with assessments of heart rate, capillary refill of 2 seconds or less, and urine output of at least 30 mL/hour. ECG changes, with the exception of heart rate, generally do net occur in hypovolemic shock.