Chapter 49: Shock, Multiple Organ Dysfunction Syndrome, and Burns in Children

MULTIPLE CHOICE
1. What is the most common type of shock in children?
a. Hypovolemic
c. Neurogenic
b. Cardiogenic
d. Septic
ANS: A

Hypovolemic shock, the most common type of shock in children, is associated with a
reduction in the intravascular volume relative to the vascular space.
PTS: 1

REF: Page 1703

2. Hypotension is likely to occur when an infant or child is greater than _____ % dehydrated.
a. 2
c. 7
b. 5
d. 10
ANS: D

Hypotension typically develops when dehydration is greater than 10% in the infant or child or
greater than 6% in the adolescent.
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REF: Page 1703

3. A prolonged capillary refill time in children is consistent with the development of what type

of shock?
a. Hypovolemic
b. Septic

c. Compensated
d. Cardiogenic

ANS: B

The child with hypovolemic shock demonstrates signs of inadequate blood flow to some
tissue beds and some evidence of organ system dysfunction. The infant or child may be
irritable or lethargic. Respirations will be rapid and may be labored if shock is severe or
associated with myocardial failure. The skin will be mottled, although pallor also may be
observed. A prolonged capillary refill time (>2 seconds) is consistent with the development of
septic shock. This statement is not necessarily true of the other types of shock.
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REF: Page 1704

4. Bradycardia in young children experiencing shock symptoms often suggests which result?
a. Onset of cardiac dysfunction
b. Effective management of cardiac dysfunction
c. Good management of anxiety
d. Cardiovascular collapse
ANS: D

Bradycardia often indicates impending cardiovascular collapse or cardiac arrest and is the
most common terminal cardiac rhythm observed in children. This selection is the only option
that accurately describes the impact of bradycardia on a child.
PTS: 1

REF: Page 1704

5. What is the cause of appropriately 50% of the deaths in children who have experienced a burn

injury?
a. Immunosuppression
b. Hypermetabolism

c. Inhalation injury
d. Hypertrophic scarring

ANS: C

The leading cause of death in children after burn injury, as in adults, is an inhalation injury.
Inhalation injuries cause approximately 50% of all deaths in children with burns. Although the
other options are factors, they are not responsible for 50% of the deaths.
PTS: 1

REF: Pages 1715-1716

6. In cardiogenic shock, what is the cause of hepatomegaly and periorbital edema?

a. Mass vasodilation as a result of chemical mediators released from the myocardium
b. Low cardiac output, causing a high central venous pressure
c. Tissue damage to the myocardium, causing increased capillary permeability
d. Low perfusion of the kidneys, stimulating the renin-angiotensin-aldosterone system

to retain sodium and water

ANS: B

Evidence of an adequate or high central venous pressure, including hepatomegaly and

periorbital edema, is observed in cardiogenic shock. This selection is the only option that
accurately identifies the cause of these symptoms.
PTS: 1

REF: Page 1704

7. Approximately 80% of all hospital-acquired infections in children are a result of which type

of organism?
a. Bacteria
b. Viruses

c. Fungi
d. Rickettsia

ANS: A

In adults and children, approximately 40% of all hospital-acquired infections are linked to
gram-negative infections, 40% to gram-positive infections, and 20% to viruses, fungi, or
rickettsial microorganisms.
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REF: Page 1707

8. Which cytokines are antiinflammatory mediators?

a. Interleukin (IL)1, IL-6, and tumor necrosis factoralpha (TNF-)
b. IL-8, IL-12, and platelet-activating factor
c. IL-24, arachidonic acid metabolites, and nitric oxide
d. IL-4, IL-11, and colony-stimulating factor
ANS: D

Antiinflammatory mediators include only IL-4, IL-10, IL-11, and IL-13; transforming growth
factor-beta; colony-stimulating factors; soluble TNF receptor; IL-1 receptor antagonist; and
activated protein C.
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REF: Page 1707

9. What type of injury is associated with cellular injury caused by the restoration of blood flow

and physiologic concentrations of oxygen to cells that have been exposed to injurious but
nonlethal hypoxic conditions?
a. Hypoxic
c. Reperfusion
b. Hyperoxygenation
d. Ischemic
ANS: C

Reperfusion (reoxygenation) injury is associated with cell damage caused by the restoration of
blood flow and physiologic concentrations of oxygen to cells that have been exposed to
injurious but nonlethal hypoxic conditions.
PTS: 1

REF: Page 1710

10. What are the primary goals for the treatment of shock?
a. Maximizing oxygen delivery and minimizing oxygen demand
b. Maintaining hydration and adequate urinary output
c. Supporting all facets to the cardiovascular system
d. Maintaining all vital signs within normal functioning ranges
ANS: A

The primary goals of the treatment of shock are maximizing oxygen delivery and minimizing
oxygen demand. Although the other options are desirable, they are each associated with the
primary goals related to oxygen delivery and demand.
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REF: Pages 1710-1711

11. To determine a childs response to fluid therapy for shock, the nurse should monitor

______________________.
a. Hematocrit and hemoglobin levels
b. Urine output and specific gravity

c. Blood pressure and pulse

d. Arterial blood gases and heart rate

ANS: B

Monitoring of the volume of urine output and specific gravity is most useful in determining
the childs response to fluid therapy.
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REF: Page 1711

12. For children who are experiencing shock, crystalloids and colloids are generally administered

in boluses of how many milliliters per kilogram (ml/kg)?

c. 15
d. 20

a. 5
b. 10

ANS: D

In general, isotonic crystalloids (salt-containing solutions, such as normal saline or lactated

Ringer solution) or colloids (protein-containing fluids, such as albumin or blood) are
administered in boluses of 20 ml/kg.
PTS: 1

REF: Page 1711

13. As the result of the inability to concentrate urine, children are at risk for dehydration before

which age?
a. 2 years

c. 6 years

b. 4 years

d. 8 years

ANS: A

Children younger than 2 years lack the ability to concentrate urine because of the immaturity
of the renal system and are therefore at increased risk for dehydration.
PTS: 1

REF: Page 1719

14. What causes renal failure after electrical burns in children?

a. Cytokines are released after the damaged tissue.
b. Immature kidneys are unable to compensate for the electrical burn.
c. Cardiac output is reduced.
d. Myoglobin is released from damaged muscles.
ANS: D

The release of myoglobin may occlude the kidney tubules and result in renal failure. This
selection is the only option that accurately describes the correlation between electrical burns
and renal failure.
PTS: 1

REF: Page 1719

15. Compared with the ebb phase, characteristics of the catabolic flow phase in metabolism after a

burn injury in a child include which process?

a. Reduced oxygen consumption
b. Elevation of catecholamines

c. Impaired circulation
d. Cellular shock

ANS: B

After the resolution of the shock and the restoration of circulating volume, the metabolic
response shifts to a catabolic (flow) phase. A state of hypermetabolism ensues, characterized
by increased oxygen consumption and the elevation of catecholamines, glucocorticoids, and
glucagon. This selection is the only option that accurately compares the characteristics of the
ebb and flow phases.
PTS: 1

REF: Page 1720

16. What advantage do impregnated silver dressings have for patients with burn injuries?
a. Impregnated silver dressings contain natural-occurring collagens.
b. They require only one dressing change every other day.
c. Removal is less painful.
d. Impregnated silver dressings are cost effective.
ANS: C

Impregnated silver dressings not only kill bacteria but most are processed with a special layer,
making them less painful to remove. Some of these products can be left on the wound for up
to 2 weeks, allowing for less frequent dressing changes. The other options are related to a new
extracellular matrix (ECM) product that is now being researched for repair and remodeling of
damaged tissues.
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REF: Page 1722 | What's New box

17. What is the most serious outcome resulting from limited glycogen stores in children who have

been seriously burned?

a. Poor wound healing

b. Increased morbidity

c. Decreased immunity
d. Loss of adipose tissue stores

ANS: B

Glycogen stores are limited in children, making it hard for them to meet the increased energy
demands of the burn. This prolonged metabolic dysfunction may lead to the loss of lean body
mass. The most serious affect is increased morbidity; that is, the risk of additional illnesses
will impede recovery. The remaining options do not represent the most serious outcome of
limited glycogen stores resulting from severe burns.
PTS: 1

REF: Page 1720

18. What is the normal range of respirations for an infant (in breaths per minute)?
a. 18 to 25
c. 27 to 37
b. 20 to 28
d. 30 to 53
ANS: D

Although the other ranges may be normal for some age groups, the normal respiratory range
for infants is 30 to 53 breaths per minute.
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REF: Page 1702 | Table 49-1

19. While awake, what is the normal heart rate for toddlers (in beats per minute)?
a. 100 to 205
c. 98 to 140
b. 100 to 180
d. 80 to 120
ANS: C

Although the other ranges may be normal for some age groups, the normal heart rate range for
toddlers during waking hours is 98 to 140 beats per minute.
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REF: Page 1702 | Table 49-1

MULTIPLE RESPONSE
20. Which statements are true regarding multiple organ dysfunction syndrome (MODS)? (Select

all that apply.)

Diagnosis requires simultaneous failure of at least two organs.
Primary MODS occurs immediately after the attributing cause.
Secondary MODS occurs within 3 to 7 days of the initial insult.
Chronic illness increases a childs risk for MODS.
Risk factors for MODS include severe or prolonged shock, sepsis, and trauma.

a.
b.
c.
d.
e.

ANS: A, D

MODS is the simultaneous failure of at least two organs resulting from a single cause and may
be either primary or secondary. Primary MODS is directly attributable to the insult and
typically occurs 3 to 7 days after an insult. Secondary MODS typically occurs later and may
be associated with the more sequential development of organ dysfunction. Risk factors for
MODS include severe or prolonged shock, sepsis, trauma, cardiopulmonary arrest, congenital
heart disease, and liver and bone marrow transplantation. Children with chronic diseases have
an increased risk for MODS and increased mortality.
PTS: 1

REF: Pages 1699-1700

21. The child with septic shock has significant hypovolemia that typically responds to which

interventions? (Select all that apply.)

Aggressive fluid administration
Antibiotic therapy
Titration of inotropes
Vasopressors
High caloric nasogastric feedings

a.
b.
c.
d.
e.

ANS: A, B, C, D

The child with septic shock has significant hypovolemia that typically responds to aggressive
fluid administration, antibiotic therapy, titration of inotropes, vasopressors, and vasodilators.
Nasogastric feedings are not generally ordered for children with septic shock.
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REF: Page 1709

22. Which behaviors in newborns would support the possibility of shock? (Select all that apply.)
a. Decreased heart rate variability
b. Temperature instability
c. Hyperalertness
d. Increased muscle tone
e. Hypoglycemia
ANS: A, B, E

Nonspecific signs of distress in newborns include jitteriness or lethargy with decreased muscle
tone, bradycardia or decreased heart rate variability, temperature instability, and
hypoglycemia.
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REF: Page 1700 | Box 49-1

23. Which assessment finding would be recognized as a late sign of shock in a child? (Select all

that apply.)
Metabolic (lactic) acidosis
Cool skin
Bradycardia
Prolonged capillary refill
Hypotension

a.
b.
c.
d.
e.

ANS: C, E

Although all of the options are observable, hypotension and bradycardia are recognized as late
signs of shock in children.
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REF: Page 1700 | Box 49-1

24. Which statements are true regarding how a childs body compensates for cardiogenic shock?

(Select all that apply.)

a. Splanchnic arteries are constricted to divert blood from the skin, kidneys, and gut to

the heart and brain.

b. Peripheral blood vessels are constricted to raise blood pressure.
c. Adrenergic responses produce tachycardia to increase cardiac output.
d. The renin-angiotensin-aldosterone system is stimulated when renal function

decreases.
e. Compensation prevents the child from developing hepatic or mesenteric failure.
ANS: A, B, C, D

In the early stages of cardiogenic shock, adrenergic compensatory mechanisms produce

tachycardia, peripheral vasoconstriction, and constriction of the splanchnic arteries to divert
blood flow from the skin, gut, and kidneys to maintain flow to the heart and brain. These
compensatory mechanisms may be sufficient to maintain the childs systolic blood pressure
and effective coronary artery and cerebral blood flow. However, tachycardia and systemic
arterial constriction increase myocardial oxygen consumption. In addition, reduction in gut
and kidney blood flow may produce hepatic, mesenteric, or renal ischemia or failure.
Decreased renal perfusion stimulates the renin-angiotensin-aldosterone system, as described
for hypovolemic shock.
PTS: 1

REF: Page 1704

25. What considerations must the nurse take into account when assessing the severity of a burn

injury? (Select all that apply.)

a. Amount of fluid lost over a 24-hour period
b. Circumference of the burn injury
c. Depth of the burn injury
d. Severity of the injury caused to other body systems
e. Percentage of total body surface area involved
ANS: C, E

The severity of a burn injury is assessed on the basis of the percentage of the total body
surface area involved. Because burn trauma represents a three-dimensional wound, the
severity of injury is also assessed in relation to the depth of the injury. Although the other
options are considered when planning treatment, the severity of the burn injury, itself, is not
based on any of these.
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REF: Pages 1716-1717

MATCHING

Match the terms with the corresponding descriptions.

______ A. Scald burn
______ B. Contact burn
______ C. Flame burn
______ D. Electrical burn
______ E. Chemical burn
26.
27.
28.
29.
30.

Involves flammable liquids such as gasoline.

Is caused by hot grease.
Is the result of direct contact with high- and low-voltage current.
Is caused by a corrosive agent.
Involves cigarette burns and curling irons.

26. ANS: C
PTS: 1
REF: Page 1716
MSC: Flame burns involving flammable liquids, especially gasoline, are most common in older
children.

27. ANS: A
PTS: 1
REF: Page 1715
MSC: Scald injuries (e.g., hot water, grease) are most common among young children.
28. ANS: D
PTS: 1
REF: Page 1716
MSC: Electrical burns are the result of direct contact with high- or low-voltage current.
29. ANS: E
PTS: 1
REF: Page 1716
MSC: Chemical burns occurring at home may be a result of swallowing corrosive agents.
30. ANS: B
PTS: 1
REF: Page 1715
MSC: Contact burns may be intentionally inflicted by contact with cigarettes or other hot objects such
as curling irons.