Question

39 Nursing Care of Patients in Shock Chapter 9 3. A 50-year-old patient who is hypotensive is receiving a fluid challenge of 1,000 mL0.9% normal saline over 4 hours. Her lung sounds are now crackles in all lung fields, Her heart rhythm is irregular. Jugular vein distention and ankle edema are present. Blood pressure has dropped from 96/50 to 80/40 mm Hg in I hour, pulse 108 bpm, respiration rate 24 breaths per minute CRITICAL THINKING Identify the stage of shock, category of shock, and initial action to take for the following patients 1. An 80-year-old woman admitted with a bowel obstruction has minimal urine output. A nasogastric tube has 1500 mL of bloody aspirate returned on insertion. She becomes comatose. Vital signs are as follows: blood pressure 78 mm Hg with Doppler stethoscope, pulse 140 bpm and thready, respiration rate 8 breaths per minute, and temperature 94"F (34°C). Stage: Category of Shock Initial Action: and temperature 95 F (35°C). She is confused. Stage:. Category of Shock: Initial Action: 2. A 56-year-old patient with chronic kidney disease who receives hemodialysis is agitated. Her blood pressure is 100/92 mm Hg. pulse 110 bpm, respiration rate 18 breaths per minute, and temperature 102 F (39°C) Stage Category of Shock Initial Action: REVIEW QUESTIONS-CONTENT REVIEW 4. The nurse is caring for a hypertensive patient whose blood pressure is usually 156/86 mm Hg. Which of the following blood pressures is considered a progressive shock blood pressure finding for this patient? 1. 90/44 mm Hg 2. 140/80 mm Hg 3. 114/64 mm Hg 4. 130/72 mm Hg Choose the best answer unless directed otherwise. 1. Which of the following actions would the nurse take to collect data to determine status of peripheral tissue perfusion in a 48-year-old patient in shock? 1. Obtain apical pulse. 2. Check capillary refill. 3. Check for sacral edema, 4. Monitor level of consciousness. 5. Which of the following outcomes for the nursing diagnosis Deficient Knowledge is appropriate for the patient recovering from shock? 1. Accepts responsibility for shock 2. States understanding of shock 3. Interacts with others 2. Which of the following does the nurse understand is the primary reason that respiration increases in compensated shock? 1. Anxiety causes hyperventilation. 2. Retention of carbon dioxide is decreased. 3. Normal oxygen levels are maintained. 4. Cardiac output is increased. 4. Verbalizes fears 3. With which of the following stages of shock would the nurse anticipate the skin to be cold and moist during data collection? 1. Compensated 2. Progressive 3. Ireversible

Answer 1

1, stage: Stage IV
Category of shock: Hemorrhagic shock
Initial action: Restore the fluid volume and control the source of bleeding
2, Stage: Stage I
Category of shock: Hypovolemic shock
Initial action: Stop the fluid loss and normalize the blood volume level.
3, stage II
Category shock: Cardiogenic shock
Initial action: Administer inotropic agents like norepinephrine or dopamine to improve heart function.
1, Check capillary refill
Ineffective tissue perfusion decrease in o2 and failure to tissue capillary level. obtaining an apical pulse, sacral edema, level of conscious will include in cardiac assessment after the initial assessment.