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)

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.
B. Obstructive shock is due to a physical obstruction of blood flow, such as a pulmonary embolism or cardiac tamponade, which does not directly correlate with the client's presentation of symptoms.
C. Cardiogenic shock results from severe heart failure and is typically accompanied by signs of heart dysfunction, not just low blood pressure and abdominal pain.
D. Septic shock is associated with infection and systemic inflammation, often presenting with fever and other signs of infection, which the client is not exhibiting.

A. Obtain pulmonary function tests B. Assess the client's blood pressure C. Administer epinephrine D. Assess the client's level of consciousness

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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