The nurse is caring for a client with cardiogenic shock. Which information obtained by the nurse would best suggest the patient is developing multiple organ dysfunction syndrome (MODS)?

The client's serum creatinine level is elevated.

The client complains of intermittent chest pressure.

The client has wheezes throughout both lung fields.

The client's extremities are cool and pulses are weak.

Answer and Explanation

The Correct Answer is A

A. Elevated serum creatinine indicates impaired renal function, which is a sign of organ dysfunction. In cardiogenic shock, decreased cardiac output reduces perfusion to vital organs, and rising creatinine is an early indicator of kidney involvement in MODS. This finding reflects multi-organ compromise rather than isolated symptoms.

B. Chest pressure reflects ongoing myocardial ischemia, which is the underlying cause of cardiogenic shock, but it does not indicate that other organs are failing.

C. Wheezing may indicate pulmonary congestion or fluid overload, but it is not specific for MODS. It reflects one organ system rather than multi-organ dysfunction.

D. Cool extremities and weak pulses indicate poor perfusion and peripheral vasoconstriction, common in shock. While concerning, these are signs of inadequate circulation rather than definitive evidence of multiple organ failure.

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Correct Answer is A

Explanation

A. Call the Rapid Response Teamis correct because the client is exhibiting life-threatening signs of deterioration. A respiratory rate of 10 breaths per minute indicates bradypnea, which can lead to hypoxia and respiratory failure if not addressed immediately. The tachycardia (pulse 136) reflects the body’s attempt to compensate for hypotension and maintain perfusion. A blood pressure of 92/78 mm Hg is borderline low and may worsen, leading to inadequate organ perfusion. The altered level of consciousness, responding only to voice, suggests decreased cerebral perfusion, a critical warning sign. These findings collectively indicate the client is in early to moderate shockand requires immediate bedside evaluation and interventionto prevent progression to irreversible shock. The Rapid Response Team brings skilled personnel and resources to stabilize the client quickly, including interventions such as airway support, intravenous fluids, and medication administration.

B. Transfer the client to the Intensive Care Unitis incorrect because while ICU care may ultimately be necessary, immediate stabilization is the priority. Rapid Response activation allows critical interventions to occur at the bedside before transfer, reducing the risk of further deterioration during transport.

C. Continue monitoring every 30 minutesis incorrect because the client’s current vital signs indicate acute instability. Waiting 30 minutes could result in respiratory failure, shock progression, or cardiac arrest. Continuous monitoring alone is insufficient.

D. Notify the unit charge nurse immediatelyis incorrect because while the charge nurse should be informed, this action does not ensure prompt bedside interventionby personnel trained to manage acute life-threatening changes. The Rapid Response Team is the recommended mechanism for urgent evaluation and treatment.

A. Neurogenic shock B. Anaphylactic shock C. Septic shock D. Hypovolemic shock

Correct Answer is A

Explanation

A. Neurogenic shockis correct because it occurs following a spinal cord injury, especially above T6, leading to loss of sympathetic nervous system tone. This results in hypotension, bradycardia, and warm, dry skindue to unopposed parasympathetic activityand peripheral vasodilation. The combination of low blood pressure, low heart rate, and warm skin is classic for neurogenic shock, distinguishing it from other types of shock.

B. Anaphylactic shockis incorrect because it usually presents with hypotension, tachycardia, and warm, flushed skin, often accompanied by urticaria, airway swelling, and respiratory distress, which are not described in this client.

C. Septic shockis incorrect because septic shock typically presents with hypotension, tachycardia, fever or hypothermia, and warm, flushed skin in the early stages. This client’s heart rate is bradycardic, not tachycardic, and he has a normal temperature, making sepsis less likely.

D. Hypovolemic shockis incorrect because it usually presents with hypotension, tachycardia, and cool, clammy skindue to decreased circulating volume and sympathetic compensatory mechanisms. This client’s skin is warm and dry, which is inconsistent with hypovolemic shock.

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The nurse is caring for a client with cardiogenic shock. Which information obtained by the nurse would best suggest the patient is developing multiple organ dysfunction syndrome (MODS)?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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