Perrin: Understanding the Essentials of Critical Care Nursing
Chapter 6: Care of the Patient Experiencing Shock or Heart Failure
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers
...
Perrin: Understanding the Essentials of Critical Care Nursing
Chapter 6: Care of the Patient Experiencing Shock or Heart Failure
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1)Which of the following should the nurse identify as symptoms of hypovolemic shock? (Select all that
apply.)
A) A temperature of 97.6°F (36.4°C)
B) A decrease in blood pressure of 20 mm Hg when the patient sits up
C) Capillary refill time greater than 3 seconds
D) Restlessness
E)Sinus bradycardia of 55 beats per minute
Answer: B, C, D
Explanation: A) (Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease
the blood to the brain by gravitational pull and will require increased peripheral
resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will
increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever
has caused severe dehydration, reducing the circulating blood volume. Hypovolemic
shock reduces temperatures by peripheral shunting of blood away from the extremities
and reducing the core metabolic rate. If septic shock is present fever might be present,
but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is
not present. The compensatory response is to increase the heart rate (tachycardia) to
circulate the blood faster to make up for the fluids that are not present in hypovolemic
shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
B)(Note: This requires multiple responses to be correct.)
Due to decreased blood flow to the brain and peripheral areas when blood is shunted to
maintain the vital organs, cerebral hypoxia occurs. The action of standing will decrease
the blood to the brain by gravitational pull and will require increased peripheral
resistance or cardiac output to maintain cerebral blood supply. #1 is incorrect. Fever will
increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever
has caused severe dehydration, reducing the circulating blood volume. Hypovolemic
shock reduces temperatures by peripheral shunting of blood away from the extremities
and reducing the core metabolic rate. If septic shock is present fever might be present,
but it is not present in all patients with hypovolemic shock. #5 is incorrect. Bradycardia is
not present. The compensatory response is to increase the heart rate (tachycardia) to
circulate the blood faster to make up for the fluids that are not present in hypovolemic
shock.
Nursing Process: Assessment
Cognitive Level: Application
Category of Need: Physiological Integrity–Physiological Adaptations
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