Today’s NCLEX-RN® question of the day focuses on cardiogenic shock. Do you know the answer? Let’s find out!
The nurse in the cardiovascular intensive care unit is assessing a patient who had a myocardial infarction (MI). Which clinical finding(s) suggest(s) the patient is experiencing cardiogenic shock? Select all that apply.
A. Weak, thready peripheral pulses
B. Blood pressure 76/52 mm Hg
C. Respiratory rate 26/min
D. Angioedema
E. Mean arterial pressure (MAP) 58 mmHg
Scroll down for the correct answer!
The correct answer to today’s NCLEX® Question is…
A. Weak, thready peripheral pulses
Rationale: Weak, thready peripheral pulses are a clinical finding associated with cardiogenic shock as the heart is unable to effectively pump blood to supply the body’s needs. As cardiac output decreases, the peripheral pulses weaken.
B. Blood pressure 76/52 mm Hg
Rationale: Hypotension, or decreased blood pressure, is a clinical finding associated with cardiogenic shock as the heart is unable to effectively pump blood to supply the body’s needs. This causes decreased cardiac output, resulting in decreased blood pressure. Hypotension for adults is when blood pressure falls below 90/60 mm Hg.
C. Respiratory rate 26/min
Rationale: Tachypnea, or an increased respiratory rate, is a clinical finding associated with cardiogenic shock. During cardiogenic shock, the heart is unable to effectively pump blood to supply the body’s needs. Eventually, blood begins to back up into the pulmonary circulation, resulting in pulmonary edema and impaired gas exchange, which further impairs oxygenation of tissues. To compensate, the heart rate and respirations increase in an attempt to improve oxygen delivery to the body. Tachypnea for adults is when the respiratory rate rises above 20 breaths per minute.
E. Mean arterial pressure (MAP) 58 mmHg
Rationale: A MAP of 58 mmHg is a clinical finding associated with cardiogenic shock. MAP is the average pressure in one cardiac cycle and is a more accurate indicator of perfusion than blood pressure. The expected MAP for an adult patient is 65 to 90 mmHg, so a MAP of 60 mmHg indicates decreased cardiac output, which occurs during cardiogenic shock as the heart is unable to effectively pump blood to supply the body’s needs.
Main Takeaway
The nurse should use clinical judgment to recognize cues related to cardiogenic shock by identifying relevant and important information from different sources. Cardiogenic shock is a life-threatening condition where the heart is unable to effectively pump blood to supply the body’s needs that can occur following conditions that cause myocardial dysfunction, like a myocardial infarction (MI) where ischemia results in death of the myocardium, or heart muscle. This impairs contractility, decreases stroke volume, and reduces cardiac output, leading to impaired tissue perfusion and decreased oxygen delivery.
As cardiac output decreases, hypotension occurs, peripheral pulses weaken, and the skin becomes cool and pale as blood is diverted to critical organs. The mean arterial pressure (MAP), or the average pressure in one cardiac cycle, decreases, which indicates poor perfusion.
Also, blood begins to back up into the pulmonary circulation, resulting in pulmonary edema and impaired gas exchange, which further impairs oxygenation of tissues. To compensate, the heart rate and respirations increase in an attempt to improve oxygen delivery to the body. Additionally, urinary output decreases as blood flow to the kidneys is reduced. Cardiogenic shock can result in severe hypoxia, multiple organ failure, and death if left untreated.
Incorrect Answer Explanations
D. Angioedema
Rationale: Angioedema, or swelling of the lips and tongue, is a clinical finding associated with anaphylactic shock rather than cardiogenic shock. Anaphylactic shock is circulatory failure that results from a severe systemic allergic reaction.
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