The nurse overseeing care in the intensive care unit (ICU) reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?
The client admitted with malignant hypertension
The client admitted following a stroke
The client admitted with acute kidney injury
The client admitted following a myocardial infarction (MI)
The Correct Answer is D
A. Malignant hypertension poses risks for other conditions but is not the primary risk factor for cardiogenic shock.
B. A stroke does not directly lead to cardiogenic shock, though it may have other significant complications.
C. Acute kidney injury affects renal function but is not the primary risk for cardiogenic shock.
D. A myocardial infarction (MI) can impair the heart's pumping ability, leading to cardiogenic shock. This is due to the damage to heart muscle that can severely impact cardiac output and blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.
Correct Answer is C
Explanation
A. Obtaining pulmonary function tests can help assess the extent of respiratory involvement but is not the immediate priority in an emergency situation like anaphylaxis.
B. Assessing blood pressure is important to monitor for signs of shock, but administering epinephrine takes precedence in treating anaphylaxis.
C. Administering epinephrine is the first-line treatment for anaphylaxis. Epinephrine rapidly reverses the symptoms of anaphylaxis, such as airway constriction and low blood pressure, making it the highest priority intervention.
D. Assessing the client's level of consciousness is important but should occur after the administration of epinephrine, which is critical in reversing the anaphylactic reaction.
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