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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urine output of less than 0.5 mL/kg
Norepinephrine is a vasopressor used to improve perfusion. A urine output of less than 0.5 mL/kg suggests ongoing hypoperfusion and inadequate organ perfusion, which is an undesirable outcome.
B. Improved mental status, decreased lactate level
These are positive indicators of improved perfusion and oxygen delivery, but they are not the primary target for norepinephrine therapy.
C. A mean arterial pressure (MAP) of 65
A MAP of at least 65 mmHg is the target for vasopressor therapy, as it ensures adequate perfusion of vital organs.
D. A pain level of 4 or less on a scale of 0-10
While pain management is important, norepinephrine’s primary role is not pain control but rather maintaining adequate perfusion.
Correct Answer is D
Explanation
A. Elevate the extremity and apply an ice pack to the injured area
Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.
B. Contact poison control to determine the best neutralizing agent
While contacting poison control is important, it should not be the immediate first action in an emergency setting.
C. Apply a sterile dressing, wrapping the fingers separately
This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.
D. Irrigate the affected area with room temperature water
Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.
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