Deck 46: Sirs, Sepsis, Shock, Mods, and Death

Question 1

While performing confirmatory tests for brain death in a client, the radiographic technician places a probe at the temporal bone above the zygomatic arch or at the vertebrobasilar arteries through the suboccipital window. Which test is being done on the client through this intervention?
1)Nuclear imaging
2)Cerebral angiography
3)Electroencephalography
4)Transcranial Doppler ultrasonography

Answer 1

4

Question 2

Which type of shock occurs as a result of injury to the spinal cord or brain?
1)Neurogenic
2)Cardiogenic
3)Anaphylactic
4)Hypovolemic

Answer 2

1

Question 3

The nurse is providing care for a client admitted to the hospital for complications related to chronic obstructive pulmonary disease. Which manifestation causes the nurse to monitor the client for the development of systemic inflammatory response syndrome (SIRS)?
1)Heart rate of 82 beats/minute
2)Respiration rate of 20 breaths/minute
3)Temperature of 96.2°F (35.7°C)
4)Leukocyte count of 11,250/mm³

Answer 3

3

Question 4

Which characteristic signs does the nurse refer to while teaching about Beck's triad? Select all that apply.
1)Stridor breath sounds
2)Low blood pressure
3)Distant heart sounds
4)Wheezing lung sounds
5)High jugular venous pressure

Question 5

After assessing the best motor response of a client using the Glasgow Coma Scale, the nurse documents the score as 6. Which response of the client supports the nurse's documentation?
1)Obeys command to move
2)Withdraws from a painful stimulus
3)Flexion, abnormal decorticate posturing
4)Extension, abnormal decerebrate posturing

Question 6

The nurse is evaluating the knowledge of staff nurses regarding the confirmatory tests for brain death. Which statement made by a staff nurse does the nurse correct?
1)"Inject technetium within 30 minutes of brain death during nuclear imaging."
2)"Obtain readings for at least 30 minutes during electroencephalography."
3)"Obtain x-ray images between 30 and 60 minutes and at 2 hours after injection during nuclear imaging."
4)"Use eight scalp electrodes with a distance of 5 centimeters between each during electroencephalography."

Question 7

What is the percentage of intensive care unit (ICU) mortality of a client with sepsis if the APACHE II score is 28?

A)40%
B)55%
C)75%
D)85%

Question 8

A client is diagnosed with systemic inflammatory response syndrome. Which physiological changes does the nurse suspect in the client with this condition? Select all that apply.
1)Increased heart rate
2)Increased urine output
3)Increased cardiac output
4)Increased respiratory rate
5)Increased gastrointestinal activity

Question 9

Which medications does the nurse find in the prescriptions of a client diagnosed with anaphylactic shock? Select all that apply.
1)Beta blockers
2)Antihistamines
3)Anticoagulants
4)Glucocorticoids
5)Anticholinergics

Question 10

Which are the events that occur during the initial stage of shock? Select all that apply.
1)The kidneys fail to filter blood wastes.
2)The sympathetic nervous system is triggered.
3)The liver and the gastrointestinal system suffer ischemia.
4)The heart and brain begin to sustain decreased perfusion.
5)The renin-angiotensin-aldosterone system (RAAS) is triggered.

Question 11

Which is an intestinal hormone that increases cellular sensitivity to insulin during shock?
1)Cortisol
2)Epinephrine
3)Vasopressin
4)Glucagon-like peptide 1 (GLP-1)

Question 12

The nurse assigns a double-point score for serum creatinine while calculating the physiological variables of a client with septic shock. For which condition is a double-point score assigned?
1)Hepatic failure
2)Acute renal failure
3)Intra-abdominal hypertension
4)Disseminated intravascular coagulopathy

Question 13

In which manner is glucose uptake blocked in the periphery during shock?
1)By increased levels of insulin
2)By decreased levels of cortisol
3)By decreased levels of incretins
4)By increased levels of norepinephrine

Question 14

After assessing the skin color and mental status of a client, the nurse concludes that the client is experiencing cardiac shock. Which finding observed in the client supports the nurse's conclusion?
1)Hives; anxious
2)Flushed; confused
3)Cyanotic; anxious
4)Pale; anxious; thirsty

Question 15

The nurse finds pulmonary infiltrates in the chest x-ray reports of a client. The arterial blood gas (ABG) reports show hypoxemia, and a white blood cell (WBC) with differential count shows leukocytosis. Which condition does the nurse suspect in the client, based on these findings?
1)Sepsis
2)Septic shock
3)Adult respiratory distress syndrome (ARDS)
4)Disseminated intravascular coagulopathy

Question 16

The nurse is providing care for a client being treated in the intensive care unit (ICU) for a major infection. The health-care provider prescribes monitoring of the blood glucose levels. Which condition does the nurse associate with the prescribed care?
1)Systemic inflammatory response syndrome
2)Multiple organ dysfunction syndrome
3)Adult respiratory distress syndrome
4)Abdominal compartment syndrome

Question 17

A client arrives in the emergency department exhibiting the manifestations of anaphylactic shock from a bee sting. The nurse determines the sting and reaction occurred approximately 45 minutes prior to arrival. Vital signs are blood pressure (BP) 100/72 mm Hg, respiratory rate (RR) 22 breaths/min, pulse (P) 80 beats/min. Urinary catheter drains 20 mL of urine. Which stage of shock does the nurse identify?
1)Inflammatory stage
2)Initial stage
3)Progressive stage
4)Irreversible stage

Question 18

The nurse is assessing a confused client admitted to the emergency department with decreased urinary output and cyanotic fingers. The nurse finds decreased blood pressure, increased heart rate, increased respiratory rate, and hypothermia. The laboratory report shows respiratory acidosis. Which condition does the nurse interpret from the findings?
1)The client has septic shock.
2)The client has cardiac shock.
3)The client has neurogenic shock.
4)The client has hypovolemic shock.

Question 19

The nurse is providing care for a client after major surgery requiring multiple blood transfusions. The health-care provider prescribes frequent laboratory testing. The nurse is asked to call immediately if the client exhibits any manifestations of disseminated intravascular coagulopathy (DIC). Which early assessment finding warrants an immediate call from the nurse?
1)Bleeding from the nose, gingiva, and IV site
2)Dyspnea, hemoptysis, and a cough
3)Mottling and coolness of the extremities
4)Petechiae and ecchymosis development

Question 20

The nurse is caring for a client admitted to the emergency department for life-threatening hypoxemia. The nurse learns the client has developed a systemic infection related to a lung infection. Which stage of the disease progression is the nurse observing in the client?
1)Sepsis
2)Septic shock
3)Multiple organ dysfunction syndrome (MODS)
4)Compensatory anti-inflammatory response syndrome (CARS)

Question 21

The nurse is assessing a group of clients in an acute care setting. Which clients are at risk of developing hypovolemic shock? Select all that apply.
1)The clients with ascites
2)The clients with tuberculosis
3)The clients with severe burns
4)The clients with Hymenoptera
5)The clients with systemic lupus erythematous

Question 22

While assessing the responses of a client using the Glasgow Coma Scale, the nurse finds that the client opens the eyes in response to voice, and verbalizes incomprehensible sounds, but does not speak any words and has no movement or posturing. What total possible points does the nurse calculate based on these findings? Record your answer as a whole number. ____________________.

Question 23

While assessing the responses of a client using the Glasgow Coma Scale, the nurse finds the client opening their eyes spontaneously, verbalizing inappropriate but comprehensible words, and withdrawing from a painful stimulus. How many total points does the nurse document in the client's assessment record based on these findings? Record your answer as a whole number. ____________________

Question 24

The nurse is assessing the physiological variables in a client with multiple organ dysfunction syndrome (MODS) using the APACHE II scoring system. During assessment, the nurse finds a temperature of 107.6°F (42°C), heart rate of 150 bpm, serum sodium levels of 125 mEq/L, serum potassium levels as 3.2 mmol/L, and a mean arterial pressure of 80 mm Hg. What total score does the nurse record from these findings? Record your answer as a whole number. ____________________