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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. is expected to be decreased for three to five days.
In the initial stages following severe burn injury, there is often oliguria (low urine output), but this is typically followed by diuresis (increased urine output) after the first 24-48 hours, not a decrease over 3-5 days.

B. will be reduced in the first 24-48 hours and will then increase.
In the first 24-48 hours following a severe burn injury, the body may undergo a state of hypovolemia and oliguria. As fluid resuscitation begins, urine output typically increases.

C. output will be greatest in the first 24 hours after the burn injury.
Although urine output may increase with proper fluid resuscitation, it is not usually greatest in the first 24 hours; the increase typically happens after the initial resuscitation period.

D. will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
While fluid resuscitation leads to an increase in urine output after the first 24-48 hours, it is not expected to be elevated right away. The kidneys may initially respond with oliguria.

A. Wearing sunglasses while symptomatic B. Applying an eye patch before sleep C. An antihistamine eye drop D. Antibiotic ophthalmic ointment

Correct Answer is B

Explanation

A. Wearing sunglasses while symptomatic

Sunglasses reduce photophobia, but they do not prevent corneal damage from dryness.

B. Applying an eye patch before sleep

Bell's palsy affects cranial nerve VII (facial nerve), leading to incomplete eye closure. This can cause corneal abrasions and dryness. An eye patch at night prevents corneal injury.

C. An antihistamine eye drop

Antihistamine eye drops may dry out the eye further, worsening the risk of corneal injury.

D. Antibiotic ophthalmic ointment

Antibiotics are not necessary unless an infection is present. Lubricating drops or artificial tears are more appropriate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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:

Correct Answer is B

Explanation

Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

Correct Answer is B

Explanation

Which of the following measures would the nurse emphasize to assist the client diagnosed with trigeminal neuralgia in managing their pain?

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

What action priority in preventing anaphylactic shock?

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)