What is the primary goal of nursing care for the patient who is diagnosed with any type of shock? To manage and treat:

increased cardiac output.

inadequate tissue perfusion.

fluid overload or deficit

vasoconstriction of vasculature.

Answer and Explanation

The Correct Answer is B

A) Increased cardiac output:
While cardiac output is an important factor in shock management, the primary goal of nursing care is not specifically to increase cardiac output. Shock typically involves inadequate tissue perfusion, which may be caused by a variety of factors including low cardiac output, vasodilation, or fluid imbalance. The focus of nursing care is to restore adequate perfusion to tissues, which may involve improving cardiac output as part of a larger therapeutic strategy.

B) Inadequate tissue perfusion:
The primary goal in the treatment of shock is to restore adequate tissue perfusion, as shock is defined by a failure of the circulatory system to supply sufficient oxygen and nutrients to the body's tissues and organs. Inadequate tissue perfusion can lead to organ dysfunction and, if not addressed, can result in organ failure and death. Nursing interventions are aimed at improving perfusion through fluid resuscitation, vasoactive medications, and other strategies to ensure that oxygen and nutrients are delivered to vital organs.

C) Fluid overload or deficit:
Managing fluid status is crucial in shock, as fluid imbalance (either overload or deficit) can exacerbate the condition. However, fluid overload or deficit is not the primary focus; rather, it is one aspect of managing inadequate tissue perfusion. For example, in hypovolemic shock, the nurse would manage fluid deficit, while in cardiogenic shock, the focus would be on optimizing fluid balance without causing overload.

D) Vasoconstriction of vasculature:
While vasoconstriction can be a compensatory mechanism in certain types of shock (e.g., hypovolemic shock), the primary goal is not to induce vasoconstriction per se. In some cases, vasodilation may occur (as in septic shock), and vasoconstriction could be harmful. The goal is to optimize the vascular tone and perfusion, which may involve vasodilation or vasoconstriction depending on the type of shock.

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Correct Answer is D

Explanation

A) Maintaining strict bedrest for first 24 hours:
While bedrest is often recommended in the early stages following a myocardial infarction (MI), the priority nursing intervention is to reduce oxygen demand on the heart, which can be achieved through pain management and controlling the workload on the heart, rather than solely relying on bedrest. Bedrest alone may not address the underlying physiological needs of the heart, such as reducing ischemia or controlling pain.

B) Measuring urine output hourly and performing daily weights:
Monitoring urine output and performing daily weights are important in managing fluid balance, especially for those with heart failure or volume overload. However, in the acute phase of an anterior wall myocardial infarction, the priority intervention is addressing the oxygen demand on the heart and providing pain relief, which is more immediate in stabilizing the client and reducing myocardial injury.

C) Keeping the environment quiet to decrease cardiac workload:
While creating a calm and quiet environment helps in reducing stress and decreasing cardiac workload, it is still secondary to actively managing the oxygen demand of the heart. Decreasing the workload of the heart is essential, but this is done more effectively through interventions such as pain management, oxygen therapy, and medications that reduce myocardial oxygen demand (e.g., nitroglycerin, beta-blockers).

D) Reducing oxygen demand and providing pain control:
This is the highest priority intervention for a client who has suffered an acute anterior wall myocardial infarction (MI). Pain from an MI increases the heart's oxygen demand and can exacerbate ischemia. Pain relief, often with morphine, not only reduces pain but also helps in vasodilation, reducing the heart's workload. Additionally, oxygen therapy should be given to ensure adequate oxygenation, and medications like beta-blockers, nitroglycerin, and ACE inhibitors are used to reduce the workload of the heart.

A. Respiratory compromise B. Hypertension C. Septic shock D. Bradycardia

Correct Answer is A

Explanation

A) Respiratory compromise
A spinal cord injury (SCI) at the level of C-3 (cervical spine) results in the loss of function of the diaphragm, which is innervated by the phrenic nerve originating from C-3 to C-5. As a result, the patient is at high risk for respiratory compromise and may require mechanical ventilation. Respiratory failure is a leading cause of death and complications in individuals with high cervical spinal cord injuries, particularly when the injury is at or above C-4.

B) Hypertension
Although spinal cord injuries can cause autonomic dysreflexia (a condition where the body’s autonomic nervous system overreacts to stimuli, leading to dangerously high blood pressure), this condition is more common in individuals with injuries above T6. At C-3, respiratory issues are the primary concern, and hypertension is not the leading cause of complications.

C) Septic shock
Septic shock can occur after any significant injury, especially if the individual develops infections (e.g., from urinary retention, pressure ulcers, or pneumonia). However, septic shock is not the main cause of complications or death related to a C-3 spinal cord injury.

D) Bradycardia
Bradycardia (a slow heart rate) can indeed be a concern in patients with SCI, especially those with injuries at or above the T1 level. However, at the level of C-3, the main cause of complications is respiratory failure, not bradycardia. While bradycardia can occur due to disruption of sympathetic nervous system control, respiratory compromise is the most critical immediate concern.

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What is the primary goal of nursing care for the patient who is diagnosed with any type of shock? To manage and treat:

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Naxlex Comprehensive Predictor Exams

Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

Correct Answer is D

Explanation

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

Correct Answer is A

Explanation

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