Deck 47: Sirs, Sepsis, Shock, Mods, and Death

Question 1

After assessing the mental status of a client using the Glasgow Coma Scale, the nurse concludes that the client has a minor head injury. Which score supports the nurse's conclusion?
1) 6
2) 10
3) 12
4) 15

Answer 1

4

Question 2

Which medications might the nurse find in the prescriptions of a client diagnosed with anaphylactic shock?
1) Beta blockers
2) Antihistamines
3) Anticoagulants
4) Glucocorticoids
5) Anticholinergics

Answer 2

2, 4

Question 3

What is the percentage of ICU mortality of a client with sepsis, if the APACHE II score is 28?
1) 40
2) 55
3) 75
4) 85

Answer 3

2

Question 4

The student nurse is documenting different stages of multiple organ dysfunction syndrome (MODS) and its associated clinical manifestations. Which documentation made by the student nurse is accurate?
1) Stage 1
2) Stage 2
3) Stage 3
4) Stage 4

Question 5

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

Question 6

The head nurse is evaluating the knowledge of a student nurse while teaching confirmatory tests for brain death. Which statement made by the student nurse does the head 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

How is glucose uptake in the periphery blocked 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 8

The nurse is caring for a client who has status asthmaticus and is admitted to the emergency department for life-threatening hypoxemia. The nurse finds that the client has developed a systemic infection due to 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 9

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
Exhibit

Question 10

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

Question 11

The nurse is teaching a group of students about shock and its specific states. The nurse states, "A specific shock state is presented with bradycardia and hypertension. Further, the condition progresses into renal, hepatic, and cerebral hypoperfusion." Which type of shock is involved in the case of extensive hypoperfusion of the tissues?
1) Neurogenic shock
2) Anaphylactic shock
3) Both A and B
4) None of the above

Question 12

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

Question 13

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

Question 14

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

Question 15

The nurse is assessing a confused client who was 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. What 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 16

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

Question 17

The nurse assigns a double point score for serum creatinine while calculating the physiologic 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 18

The nurse finds pulmonary infiltrates in the chest x-ray reports of a client. The arterial blood gas reports show hypoxemia, and a 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
4) Disseminated intravascular coagulopathy

Question 19

The nurse is caring for four clients diagnosed with different systemic illnesses. Which client requires monitoring of the blood glucose levels?
1) Client 1
2) Client 2
3) Client 3
4) Client 4

Question 20

While teaching a group of student nurses about post-mortem changes, the nurse states, "This is a purple-red discoloration that appears on the dependent portions of the body after the heart stops." Which post-mortem change does the nurse refer to in the teaching?
1) Algor mortis
2) Rigor mortis
3) Livor mortis
4) Tardieu spots

Question 21

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 of42⁰C, heart rate of 150 bpm, serum sodium levels of 125 mEq/L, serum potassium levels as 3.2 mmol/Landa mean arterial pressure of 80 mm Hg. What total score does the nurse record from these findings? Record your answer as a whole number. ____________________

Question 22

While assessing the responses of a client using the Glasgow Coma Scale, the nurse finds that the client opens his/her eyes in response to voice, verbalizing 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

What are the events that occur during the initial stage of shock?
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 rennin-angiotensin-aldosterone system (RAAS) is triggered.

Question 24

The nurse is assessing a group of clients in a community health care setting. Which groups of clients are at risk of developing hypovolemic shock?
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
Completion
Complete each statement.

Question 25

While assessing the responses of a client using the Glasgow Coma Scale, the nurse finds that the client opens his/her eyes spontaneously, verbalizes inappropriate but comprehensible words, and withdraws from a painful stimulus. What total possible points does the nurse document in the client's assessment record based on these findings? Record your answer as a whole number. ____________________