Complete the following sentence with one of the options regarding the pathophysiology of this type of shock.
The nurse is caring for an elderly patient from a nursing home diagnosed with a urinary tract infection. The nurse assesses the patient as hypotensive, tachycardic, febrile, tachypneic, and with an altered mental status. The nurse understands that the pathophysiology of this type of shock is caused by___

Massive blood loss leading to decreased oxygen delivery to tissues

Severe allergic reaction causing systemic vasodilation and increased capillary permeability

Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion

Cardiac failure resulting in inadequate tissue perfusion and oxygenation

Answer and Explanation

The Correct Answer is C

A. Massive blood loss leading to decreased oxygen delivery to tissues

This describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.

B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability

This describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.

C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion

This patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.

D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

This describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.

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Correct Answer is C

Explanation

A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.

B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).

C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.

D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.

A. Provide the daughter and client with nutritional counseling B. Interview the client alone and assess for abuse C. Take the history from the daughter because of the client's confusion D. Request a psychiatric evaluation for the client

Correct Answer is B

Explanation

A. Provide the daughter and client with nutritional counseling.

While nutrition is important, assessing for abuse is the priority.

B. Interview the client alone and assess for abuse.

The client’s reluctance and daughter’s interruptions suggest potential elder abuse.

C. Take the history from the daughter due to the client’s confusion.

The client should be interviewed alone first.

D. Request a psychiatric evaluation.

Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?

The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

The nurse is caring for a client who presents with a chemical burn to the right hand, what should the nurse do first?

The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

What is the goal of treatment for the client diagnosed with cardiogenic shock?

The client who is experiencing septic shock is started on norepinephrine by intravenous drip via pump. Which frequent assessments should the nurse prioritize while administering this medication? (Select All that Apply)

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?