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 D

Explanation

A. Gently cleanse the wounds with warm soapy water

Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.

B. Remove blistered skin and cover with a dry dressing

Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.

C. Apply saline-soaked wet-to-dry dressings

Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.

D. Cover with a clean dry sheet to prevent hypothermia

Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.

A. monitoring for dysrhythmias B. monitoring for bleeding. C. adherence to their antihypertensive drugs D. preventing thrombus formation.

Correct Answer is C

Explanation

A. Monitoring for dysrhythmias
While cardiovascular health is important, dysrhythmias are not a primary concern in a small abdominal aortic aneurysm.

B. Monitoring for bleeding
While aneurysms can rupture, a small aneurysm is managed medically with blood pressure control, making bleeding less of an immediate concern.

C. Adherence to their antihypertensive drugs
Hypertension increases pressure on the aneurysm, increasing the risk of expansion and rupture. Strict adherence to antihypertensive medications is essential for preventing complications.

D. Preventing thrombus formation
While thrombus formation can occur in large aneurysms, it is not the primary focus in a small, medically managed aneurysm.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?

Correct Answer is D

Explanation

The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

Correct Answer is C

Explanation

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

The client admitted with sickle cell anemia crisis is being treated with a transfusion of 2 units of packed red blood cells (PRBC's) for a low hemoglobin. The cent demonstrating a new onset of chest pain. low back pain, tachycardia and anxiety. The nurse's immediate intervention is

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A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

A client receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter inserted. When evaluating the client's intake and output, which of the following should be taken into consideration? The amount of urine:

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