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A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

Decreased cardiac output.

Increased pulse rate.

Postural hypotension.

Bounding pulse.

Weak thready pulse.

Hypertension.

Capillary refill greater than 3 seconds.

Capillary refill less than 3 seconds.

Pink frothy sputum.

Answer and Explanation

Correct Answer : A,B,E,G,I

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

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Correct Answer is ["C","D","F","G","H"]

Explanation

Choice A reason: Hypertension is not typical in anaphylactic shock, which causes vasodilation and hypotension. Hypotension is a key finding, making this incorrect, as it contradicts the expected cardiovascular response in the nurse’s assessment of a client with anaphylactic shock.

Choice B reason: Crackles indicate fluid overload or pneumonia, not anaphylaxis, which causes bronchoconstriction and wheezing. Pruritus is typical, making this incorrect, as it doesn’t align with the respiratory findings the nurse would expect in anaphylactic shock assessment.

Choice C reason: Cutaneous cyanosis reflects poor oxygenation from airway compromise in anaphylactic shock. This aligns with integumentary and respiratory assessment, making it a correct finding the nurse would identify in a client experiencing anaphylactic shock in the ED.

Choice D reason: Pruritus, often with hives, is a hallmark of anaphylactic shock due to histamine release. This aligns with allergic response assessment, making it a correct finding the nurse would expect in a client with anaphylactic shock in the emergency department.

Choice E reason: Cough may occur but is less specific than wheezing, which indicates bronchoconstriction in anaphylaxis. Hypotension is more critical, making this incorrect, as it’s not a primary finding compared to the nurse’s expected signs of anaphylactic shock.

Choice F reason: Wheezing results from bronchoconstriction in anaphylactic shock, reflecting airway narrowing. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

Choice G reason: Hypotension is a cardinal sign of anaphylactic shock due to vasodilation and fluid shifts. This aligns with cardiovascular assessment, making it a correct finding the nurse would identify in a client with anaphylactic shock in the emergency setting.

Choice H reason: Restlessness indicates hypoxia or anxiety in anaphylactic shock, a common neurological response. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

A. The need to check the client’s urinary specific gravity. B. The need to take blood pressure at least twice a day. C. The need to monitor blood glucose every day. D. The need to weigh every day and report weight gain.

Correct Answer is D

Explanation

Choice A reason: Checking urinary specific gravity monitors DI control but is less critical than detecting fluid retention from desmopressin, which can cause hyponatremia. Daily weighing identifies weight gain, making this incorrect, as it’s secondary to the nurse’s priority teaching on preventing serious drug-related complications.

Choice B reason: Monitoring blood pressure is relevant for cardiovascular health but not the primary concern with desmopressin, which risks fluid overload. Daily weighing detects this, making this incorrect, as it’s less specific than the nurse’s teaching to monitor for weight gain in DI treatment.

Choice C reason: Blood glucose monitoring is unrelated to desmopressin or DI, which affects water balance, not glucose. Weighing daily addresses fluid retention, making this incorrect, as it’s irrelevant compared to the nurse’s priority teaching on managing desmopressin’s fluid-related side effects in DI.

Choice D reason: Daily weighing and reporting weight gain is the priority teaching, as desmopressin can cause fluid retention, leading to hyponatremia. This aligns with DI therapy safety, making it the correct teaching to prevent complications, ensuring the client monitors for this critical adverse effect of desmopressin.

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A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

Correct Answer is ["C","D","F","G","H"]

Explanation

A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy?

Correct Answer is D

Explanation

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