MCQ Quiz: Shock States

Shock is a life-threatening medical emergency characterized by the circulatory system’s inability to provide adequate oxygen and nutrients to tissues, leading to cellular dysfunction and organ failure. As a critical care pharmacist, a deep understanding of the pathophysiology, hemodynamics, and management of different shock states is paramount. The Patient Care VII curriculum dedicates a significant module to Acute Care/Critical Care, covering the principles of shock management, including the four major types: distributive, cardiogenic, hypovolemic, and obstructive. This quiz will test your knowledge on identifying and managing these complex emergencies, from interpreting hemodynamic parameters to selecting the appropriate pharmacotherapy.

1. Shock is fundamentally defined as:

• a) Low blood pressure
• b) A state of inadequate tissue perfusion and oxygenation
• c) High heart rate
• d) A severe infection Answer: b) A state of inadequate tissue perfusion and oxygenation

2. A patient presents with a blood pressure of 80/40 mmHg, heart rate of 125 bpm, a high cardiac index, and a very low systemic vascular resistance (SVR). This hemodynamic profile is most consistent with which type of shock?

• a) Cardiogenic Shock
• b) Hypovolemic Shock
• c) Obstructive Shock
• d) Distributive Shock Answer: d) Distributive Shock

3. What is the most common cause of distributive shock in the ICU?

• a) Anaphylaxis
• b) Neurogenic injury
• c) Sepsis
• d) Myocardial infarction Answer: c) Sepsis

4. The first-line pharmacologic agent for a patient in septic shock who remains hypotensive despite adequate fluid resuscitation is:

• a) Dobutamine
• b) Norepinephrine
• c) Phenylephrine
• d) Milrinone Answer: b) Norepinephrine

5. A patient with a massive pulmonary embolism develops shock. This is classified as which type of shock?

• a) Distributive
• b) Cardiogenic
• c) Obstructive
• d) Hypovolemic Answer: c) Obstructive

6. A patient presents with hypotension, cool and clammy skin, a low cardiac index, and a high pulmonary capillary wedge pressure (PCWP). These findings are classic for:

• a) Septic shock
• b) Anaphylactic shock
• c) Cardiogenic shock
• d) Hypovolemic shock Answer: c) Cardiogenic shock

7. The primary treatment for a patient in hypovolemic shock due to hemorrhage is:

• a) Administration of vasopressors
• b) Administration of inotropes
• c) Aggressive fluid resuscitation with crystalloids and blood products
• d) Administration of diuretics Answer: c) Aggressive fluid resuscitation with crystalloids and blood products

8. Which of the following is a key pathophysiological feature of all forms of distributive shock?

• a) Severe pump failure
• b) Widespread vasodilation
• c) Physical obstruction of blood flow
• d) Loss of intravascular volume Answer: b) Widespread vasodilation

9. Dobutamine is an inotropic agent often used in cardiogenic shock. Its primary mechanism of action is:

• a) Agonism at alpha-1 adrenergic receptors
• b) Agonism at beta-1 adrenergic receptors, increasing contractility
• c) Agonism at vasopressin receptors
• d) Antagonism at beta-2 adrenergic receptors Answer: b) Agonism at beta-1 adrenergic receptors, increasing contractility

10. According to the “Management of Patients with Sepsis” unit, what is a crucial intervention that must be performed within the first hour of recognizing sepsis?

• a) Administration of broad-spectrum antibiotics
• b) Initiation of parenteral nutrition
• c) Placement of a central venous catheter
• d) Starting stress ulcer prophylaxis Answer: a) Administration of broad-spectrum antibiotics

11. Which type of shock is characterized by low cardiac output, high systemic vascular resistance, and low central venous pressure (CVP)?

• a) Septic shock
• b) Neurogenic shock
• c) Hypovolemic shock
• d) Cardiogenic shock Answer: c) Hypovolemic shock

12. The management of obstructive shock due to cardiac tamponade requires which immediate intervention?

• a) Thrombolysis
• b) Needle decompression
• c) Pericardiocentesis
• d) Administration of norepinephrine Answer: c) Pericardiocentesis

13. Vasopressin is sometimes added as a second-line agent in septic shock. It works by acting on which receptors to cause vasoconstriction?

• a) V1 receptors
• b) V2 receptors
• c) Beta-1 receptors
• d) Alpha-1 receptors Answer: a) V1 receptors

14. A patient in the ICU is diagnosed with Acute Decompensated Heart Failure (ADHF) and is found to be “wet and cold.” What does this classification signify?

• a) The patient is congested and has adequate perfusion.
• b) The patient is not congested but is hypoperfused.
• c) The patient is both congested and hypoperfused.
• d) The patient is dehydrated and has adequate perfusion. Answer: c) The patient is both congested and hypoperfused.

15. Phenylephrine is a vasopressor that causes vasoconstriction through pure agonism at which receptors?

• a) Beta-1
• b) Beta-2
• c) Alpha-1
• d) Dopamine Answer: c) Alpha-1

16. What is the primary initial fluid of choice for resuscitation in most shock states?

• a) 5% Dextrose in water (D5W)
• b) Colloids like albumin
• c) Balanced crystalloids like Lactated Ringer’s or Plasma-Lyte
• d) Hypertonic saline Answer: c) Balanced crystalloids like Lactated Ringer’s or Plasma-Lyte

17. In which type of shock would the administration of large volumes of IV fluids be potentially harmful by worsening pulmonary congestion?

• a) Hypovolemic shock
• b) Septic shock
• c) Cardiogenic shock
• d) Anaphylactic shock Answer: c) Cardiogenic shock

18. The “Principles of Shock Management” lecture emphasizes monitoring for end-organ perfusion. Which of the following is a key indicator of adequate perfusion?

• a) Decreasing serum lactate levels
• b) Absent peripheral pulses
• c) Low urine output
• d) Altered mental status Answer: a) Decreasing serum lactate levels

19. Anaphylactic shock is a type of distributive shock. Besides fluids and vasopressors, what is the most critical first-line medication?

• a) An H2 blocker like famotidine
• b) An inhaled corticosteroid
• c) Intramuscular epinephrine
• d) An oral antihistamine Answer: c) Intramuscular epinephrine

20. A patient with severe bradycardia develops hypotension and signs of shock. According to the ACLS algorithm, what is the first-line drug therapy?

• a) Atropine
• b) Epinephrine infusion
• c) Dopamine infusion
• d) Amiodarone Answer: a) Atropine

21. Milrinone is an inotrope that works by what mechanism?

• a) It is a phosphodiesterase-3 (PDE-3) inhibitor, leading to increased intracellular calcium and contractility.
• b) It is a direct beta-1 agonist.
• c) It is a calcium-sensitizing agent.
• d) It is a pure alpha-1 agonist. Answer: a) It is a phosphodiesterase-3 (PDE-3) inhibitor, leading to increased intracellular calcium and contractility.

22. A major difference between norepinephrine and phenylephrine is that norepinephrine also has:

• a) Pure alpha-1 agonist activity
• b) Beta-1 agonist activity, which can increase heart rate and contractility
• c) Beta-2 agonist activity, causing vasodilation
• d) No effect on blood pressure Answer: b) Beta-1 agonist activity, which can increase heart rate and contractility

23. The qSOFA (quick Sequential Organ Failure Assessment) score is a tool used to identify patients with suspected infection who are at high risk for developing:

• a) Cardiogenic shock
• b) Sepsis and poor outcomes
• c) Hypovolemic shock
• d) Obstructive shock Answer: b) Sepsis and poor outcomes

24. The pathophysiology of cardiogenic shock involves a primary failure of the heart’s ________, as covered in the cardiovascular pathophysiology course.

• a) Electrical conduction system
• b) Pumping function (contractility)
• c) Valvular structure
• d) Pericardial sac Answer: b) Pumping function (contractility)

25. A patient with septic shock who is refractory to norepinephrine and vasopressin may be a candidate for what adjunctive therapy?

• a) Intravenous hydrocortisone
• b) High-dose N-acetylcysteine
• c) Intravenous immunoglobulin (IVIG)
• d) A statin Answer: a) Intravenous hydrocortisone

26. The main therapeutic goal in managing any shock state is to:

• a) Normalize the heart rate.
• b) Restore adequate tissue perfusion and oxygen delivery.
• c) Achieve a specific blood pressure number.
• d) Decrease the white blood cell count. Answer: b) Restore adequate tissue perfusion and oxygen delivery.

27. Dopamine’s effects are dose-dependent. At low doses, it primarily stimulates dopamine receptors, while at higher doses it stimulates:

• a) Only alpha-1 receptors
• b) Only beta-1 receptors
• c) Both beta-1 and alpha-1 receptors
• d) Only V1 receptors Answer: c) Both beta-1 and alpha-1 receptors

28. A patient involved in a severe motor vehicle accident is hypotensive and tachycardic. The most likely type of shock is:

• a) Septic
• b) Anaphylactic
• c) Neurogenic
• d) Hypovolemic (hemorrhagic) Answer: d) Hypovolemic (hemorrhagic)

29. The “warm shock” presentation, characterized by warm extremities and brisk capillary refill, is classic for the early stages of which shock type?

• a) Cardiogenic
• b) Hypovolemic
• c) Distributive (septic)
• d) Obstructive Answer: c) Distributive (septic)

30. The pharmacist’s role on ICU rounds during the management of a shock state includes:

• a) Recommending appropriate vasopressor/inotropes and titrations.
• b) Ensuring appropriate antibiotic selection and dosing in sepsis.
• c) Recommending and dosing fluids and electrolytes.
• d) All of the above. Answer: d) All of the above.

31. In the management of neurogenic shock, which is characterized by hypotension and bradycardia, what is the primary pathophysiologic cause?

• a) Widespread infection
• b) Loss of sympathetic tone due to spinal cord injury
• c) Severe pump failure
• d) Blood loss Answer: b) Loss of sympathetic tone due to spinal cord injury

32. The Surviving Sepsis Campaign guidelines recommend targeting a mean arterial pressure (MAP) of at least:

• a) 55 mmHg
• b) 65 mmHg
• c) 85 mmHg
• d) 95 mmHg Answer: b) 65 mmHg

33. Which of the following is NOT one of the four main categories of shock discussed in the Patient Care VII curriculum?

• a) Distributive
• b) Cardiogenic
• c) Metabolic
• d) Obstructive Answer: c) Metabolic

34. A patient with ADHF is receiving a continuous infusion of a loop diuretic. What must be monitored closely?

• a) Blood pressure
• b) Renal function (BUN, SCr)
• c) Electrolytes (K+, Mg++)
• d) All of the above Answer: d) All of the above

35. Epinephrine is considered a “dirty” vasopressor by some because it has potent effects on which receptors?

• a) Only alpha-1
• b) Only beta-1
• c) Both alpha-1 and beta-2
• d) Alpha-1, beta-1, and beta-2 Answer: d) Alpha-1, beta-1, and beta-2

36. A key difference between dobutamine and milrinone is that milrinone causes more:

• a) Vasoconstriction
• b) Vasodilation and potential for hypotension
• c) Bradycardia
• d) Renal toxicity Answer: b) Vasodilation and potential for hypotension

37. The “Principles of Shock Management” include identifying and treating the underlying cause. Which shock state is a classic example where definitive treatment involves relieving a physical blockage?

• a) Obstructive Shock
• b) Septic Shock
• c) Hypovolemic Shock
• d) Neurogenic Shock Answer: a) Obstructive Shock

38. Why is it important to obtain blood cultures before administering antibiotics in a patient with suspected sepsis?

• a) Antibiotics can sterilize the blood cultures, making it difficult to identify the causative organism.
• b) It is a hospital billing requirement.
• c) The antibiotics will not work if cultures are not drawn first.
• d) It is not important; the order does not matter. Answer: a) Antibiotics can sterilize the blood cultures, making it difficult to identify the causative organism.

39. In a patient with cardiogenic shock and severe hypotension, which agent might be added to dobutamine to increase blood pressure?

• a) A diuretic
• b) A vasodilator like nitroglycerin
• c) A vasopressor like norepinephrine
• d) A beta-blocker Answer: c) A vasopressor like norepinephrine

40. A patient’s lactate level is a marker of:

• a) Infection severity
• b) Anaerobic metabolism and tissue hypoperfusion
• c) Liver function
• d) Kidney function Answer: b) Anaerobic metabolism and tissue hypoperfusion

41. The initial fluid bolus recommended for most adults in septic shock is:

• a) 10 mL/kg of crystalloid
• b) 30 mL/kg of crystalloid
• c) 500 mL of albumin
• d) 1 L of D5W Answer: b) 30 mL/kg of crystalloid

42. Which shock state is LEAST likely to present with low central venous pressure (CVP)?

• a) Hypovolemic shock
• b) Septic shock
• c) Cardiogenic shock
• d) Hemorrhagic shock Answer: c) Cardiogenic shock

43. A patient with pulmonary hypertension can develop obstructive shock due to acute:

• a) Left ventricular failure
• b) Right ventricular failure
• c) Sepsis
• d) Dehydration Answer: b) Right ventricular failure

44. A pharmacist’s role in managing shock states extends to adjusting doses of maintenance medications based on:

• a) The patient’s preference.
• b) The presence of organ dysfunction (e.g., acute kidney injury).
• c) The cost of the medication.
• d) The time of day. Answer: b) The presence of organ dysfunction (e.g., acute kidney injury).

45. The “cold and dry” patient in ADHF is hypoperfused but not congested. What is a potential therapy?

• a) Aggressive diuresis
• b) Cautious fluid administration
• c) Vasopressors
• d) Beta-blockade Answer: b) Cautious fluid administration

46. All vasopressors should ideally be administered through which type of IV line to minimize the risk of extravasation?

• a) A peripheral IV in the hand
• b) A central venous catheter
• c) An intraosseous line
• d) Any line is acceptable. Answer: b) A central venous catheter

47. A “fluid challenge” is a technique used to assess:

• a) A patient’s fluid responsiveness
• b) A patient’s level of consciousness
• c) A patient’s pain level
• d) A patient’s renal function Answer: a) A patient’s fluid responsiveness

48. In the management of septic shock, what is the rationale for de-escalating antibiotic therapy?

• a) To increase the risk of resistance.
• b) To narrow the antibiotic spectrum once culture results are available, reducing side effects and resistance pressure.
• c) To save the hospital money.
• d) To switch to oral antibiotics immediately. Answer: b) To narrow the antibiotic spectrum once culture results are available, reducing side effects and resistance pressure.

49. A patient in cardiogenic shock has a MAP of 55 mmHg. The team wants to start an inotrope. Which agent has the least effect on blood pressure and may even lower it?

• a) Norepinephrine
• b) Epinephrine
• c) Dobutamine
• d) Milrinone Answer: d) Milrinone

50. The successful management of any shock state is highly dependent on:

• a) Using only one medication.
• b) Continuous monitoring, frequent reassessment, and treating the underlying cause.
• c) The pharmacist making all decisions independently.
• d) Following a rigid, unchangeable protocol. Answer: b) Continuous monitoring, frequent reassessment, and treating the underlying cause.