When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal?

Question

A) Provide a detailed diagnosis and plan of care in order to promote the patient's and family's coping.
B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions.
C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature.
D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment.

Answer 1

Ans: D
Feedback:
Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the patient with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the physician updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the patient the best chance for survival. Monitoring for significant changes is critical, and evaluating patient outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.