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 A
Explanation
A. Immediate removal of the cause of obstruction.
Cardiac tamponade is a life-threatening condition caused by fluid accumulation in the pericardium, which compresses the heart. The definitive treatment is pericardiocentesis to remove the fluid and relieve the obstruction.
B. Patient will be admitted for a cardiac catheterization.
While catheterization may be performed later for underlying cardiac disease, tamponade requires urgent intervention, not just admission.
C. Administering furosemide for its diuretic effects.
Diuretics reduce preload, which can worsen hypotension in tamponade by further decreasing cardiac output.
D. Withholding IV fluids due to fluid overload.
IV fluids may be used to maintain preload while waiting for pericardiocentesis. The issue is not volume overload but rather mechanical obstruction.
Correct Answer is A
Explanation
A. Fluid resuscitation
Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.
B. Transfer to a burn center
While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.
C. Application of sterile dressings
Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.
D. Administer morphine 8 mg IV
Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.
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