Chapter 65--Multisystem Failure

Chapter 65--Multisystem Failure MULTIPLE CHOICE 1. The nurse is caring for a client who has sustained multiple injuries from a motor vehicle accident. The nurse realizes that the client will have a release of stress h ...

Chapter 65--Multisystem Failure MULTIPLE CHOICE 1. The nurse is caring for a client who has sustained multiple injuries from a motor vehicle accident. The nurse realizes that the client will have a release of stress hormones that are useful for all of the following EXCEPT: 1. preventing loss of fluids. 2. preventing hypotension. 3. preventing infection. 4. preventing ingestion of food. PTS: 1 DIF: Analyze REF: Neuroendocrine System Response 2. The nurse is planning care for a client diagnosed with acute respiratory distress syndrome (ARDS)? Which of the following is not included in the management of this disorder? 1. Treating the underlying cause 2. Promoting gas exchange 3. Providing oxygen therapy 4. Promoting urine output PTS: 1 DIF: Apply REF: Acute Respiratory Distress Syndrome: Planning and Implementation 3. The nurse, caring for a client diagnosed with shock, realizes that the stage in which the body attempts to remedy the problem by initiating the homeostatic mechanism would be? 1. Initial stage 2. Compensatory stage 3. Multiple organ failure stage 4. Refractory stage PTS: 1 DIF: Analyze REF: The Four Stages of the Shock Syndrome 4. A client experiences a bee sting, complains of difficulty breathing, and shows sign of hypoxia and hypotension. The nurse realizes these are signs of anaphylactic shock, and she should do which of the following first? 1. Get a medical alert bracelet for the patient. 2. Give epinephrine intravenously or via endotracheal tube. 3. Check with the family for a history. 4. Admit the client through the admitting department. PTS: 1 DIF: Apply REF: Anaphylactic Shock: Pharmacology 5. A client is diagnosed with failure of the left ventricle to provide adequate delivery of oxygen to the body tissues due to a weakened forward pumping function of the heart. The nurse realizes this client is experiencing: 1. anaphylactic reaction. 2. cardiogenic shock. 3. hypovolemia. 4. metabolic acidosis. PTS: 1 DIF: Analyze REF: Cardiogenic Shock 6. To assess if the renal system in a client diagnosed with multisystem failure is functioning properly, the nurse would expect to see urine output of: 1. 10 mL per hour. 2. 20 mL per hour. 3. 30 mL per hour. 4. 40 mL per hour. PTS: 1 DIF: Apply REF: Box 65-6 Selected Manifestations of Cardiogenic Shock 7. The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for developing: 1. skin breakdown. 2. sweating. 3. deep vein thrombosis. 4. infection. PTS: 1 DIF: Analyze REF: Neurogenic Shock: Pathophysiology 8. A client is diagnosed with septic shock. The nurse realizes that the major cause of this type of shock is: 1. gram-negative bacteria. 2. gram-positive bacteria. 3. fungi. 4. viruses. PTS: 1 DIF: Analyze REF: Septic Shock: Pathophysiology 9. A client is diagnosed with cardiogenic shock. The nurse should plan interventions to address which of the following potential complications of this disorder? 1. Pulmonary embolism 2. Deep vein thrombosis 3. Renal failure 4. Myocardial infarction PTS: 1 DIF: Apply REF: Cardiogenic Shock: Pathophysiology 10. The nurse is concerned that a client will develop neurogenic shock when which of the following is assessed? 1. Fractured left lower extremity 2. Spinal cord injury at T1 3. Jugular vein distention 4. Sluggish bowel sounds PTS: 1 DIF: Analyze REF: Neurogenic Shock 11. The nurse is planning care for a client diagnosed with disseminated intravascular coagulation. Which of the following should be included in this plan of care? 1. Avoid intramuscular injections. 2. Provide adequate daily caloric intake. 3. Perform range-of-motion exercises to all extremities twice a day. 4. Restrict fluids. PTS: 1 DIF: Apply REF: Disseminated Intravascular Coagulation 12. A firefighter is brought to the emergency department with complaints of headache, weakness, shortness of breath, cough, and chest pain. During the assessment of this client, the nurse realizes the client should be evaluated for: 1. cyanide poisoning. 2. pulmonary emboli. 3. pneumonia. 4. stroke. PTS: 1 DIF: Analyze REF: Red Flag: Fires, Smoke Inhalation and Cyanide Poisoning MULTIPLE RESPONSE 1. The nurse is assessing a client for the acute phase of the inflammatory immune response. Which of the following are considered cardinal signs of this response? (Select all that apply.) 1. Rubor 2. Tumor 3. Dolor 4. Scarring 5. Calor 6. Loss of function PTS: 1 DIF: Apply REF: Inflammatory Immune Response; Nursing Strategy Feature: Cardinal Signs of Infection 2. The nurse is determining if a client is experiencing chronic inflammation. Which of the following are indications for this type of inflammation? (Select all that apply.) 1. Chronic elevation of white blood cells 2. Low-grade fever 3. Pain 4. Scar formation 5. Low blood pressure 6. Hematuria PTS: 1 DIF: Analyze REF: Box 65-1 Characterizations of Chronic Inflammation 3. The nurse is assessing a client for systemic inflammatory response syndrome (SIRS). Which of the following disease processes are associated with this syndrome? (Select all that apply.) 1. Infection 2. Pancreatitis 3. Ischemia 4. Trauma 5. Massive transfusions 6. Heart failure PTS: 1 DIF: Analyze REF: Systemic Inflammatory Response Syndrome 4. A client is experiencing symptoms associated with distributive shock. What types of shock are included in this category? (Select all that apply.) 1. Neurogenic 2. Hypovolemic 3. Anaphylactic 4. Cardiogenic 5. Septic 6. Chronic PTS: 1 DIF: Analyze REF: Shock Syndrome 5. The nurse is caring for a client experiencing hypovolemic shock. Which of the following interventions would be appropriate for this client? (Select all that apply.) 1. Monitor intravenous fluid replacement 2. Monitor vital signs 3. Assess for manifestations of fluid overload 4. Monitor white blood cell count and hemoglobin and hematocrit levels 5. Position for comfort 6. Assist to a sitting position PTS: 1 DIF: Apply REF: Nursing Strategy: Management of Hypovolemic Shock