Types of Shock: Hypovolemic, Distributive, Cardiogenic, and Obstructive Practice Questions

25 multiple-choice questions on Types of shock: hypovolemic, distributive, cardiogenic, and obstructive for paramedic and EMT students, from Chapter 41 (Management and Resuscitation of the Critical Patient). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A 78-year-old has a heart rate of 32 with a wide escape rhythm, a BP of 70/40 mmHg, cool skin, and clear lungs. The shock is best classified as:

   1. A. Cardiogenic, from a rate too slow to perfuse
   2. B. Hypovolemic, from poor fluid intake at home
   3. C. Distributive, from a loss of vascular tone
   4. D. Obstructive, from blocked ventricular filling
   Show answer

   Answer: A. Cardiogenic, from a rate too slow to perfuse

   Cardiac output is heart rate times stroke volume, so a heart rate of 32 can produce pump failure even when the muscle and volume are normal; this is cardiogenic shock from a rate problem, treated with pacing or a chronotropic drug per protocol. Clear lungs do not exclude cardiogenic shock. Hypovolemia would cause a fast, not slow, rate. Distributive shock causes vasodilation with warm skin, and his skin is cool. Obstructive shock needs a mechanical block such as tamponade or tension pneumothorax, and nothing here suggests one.

2. A 6-month-old with five days of diarrhea is lethargic with a sunken fontanelle, dry mucous membranes, and no wet diapers today. The type of shock is:

   1. A. Cardiogenic
   2. B. Obstructive
   3. C. Hypovolemic
   4. D. Neurogenic
   Show answer

   Answer: C. Hypovolemic

   Fluid loss from diarrhea without blood loss is non-hemorrhagic hypovolemic shock, common in infants because of their high fluid turnover. Neurogenic shock requires a spinal cord injury and is not suggested here.

3. After 3 L of crystalloid for septic shock, a 66-year-old now has crackles, cool mottled legs, and a BP of 80/48 mmHg. The added problem is most likely:

   1. A. A return of normal tone in the blood vessels
   2. B. A delayed allergic reaction to the fluid given
   3. C. Sepsis-induced depression of heart function
   4. D. The infection clearing after initial treatment
   Show answer

   Answer: C. Sepsis-induced depression of heart function

   Septic shock often includes myocardial depression (septic cardiomyopathy), so after volume is restored some patients develop cool, mottled skin and pulmonary congestion while staying hypotensive: a cardiogenic component on top of distributive shock. More fluid will worsen the lungs; the next step is a vasopressor, with an inotrope considered in hospital. Recovery of vascular tone would raise, not lower, the pressure. A fluid allergy would cause hives or bronchospasm. An infection does not clear within the first hours of treatment, and clearing would improve, not worsen, the picture.

4. A 52-year-old with a kidney infection has warm skin and a BP of 82/46 mmHg. His weight and fluid intake are unchanged. The first liter of crystalloid mainly corrects:

   1. A. Relative hypovolemia from dilated, leaky vessels
   2. B. Heavy fluid loss from his fever and sweating
   3. C. Pump failure caused by circulating bacterial toxins
   4. D. Low oncotic pressure from protein lost in his urine
   Show answer

   Answer: A. Relative hypovolemia from dilated, leaky vessels

   In septic shock, vasodilation and capillary leak enlarge the vascular space and move fluid into the tissues, so the circulating volume is too small for the container even though total body water has not fallen. Early fluid fills that gap. Sepsis can also depress the heart, but that is a later problem and does not explain why the first liter helps.

5. A 72-year-old nursing home resident with a urinary catheter is confused, RR 24, BP 96/58 mmHg, and has a temperature of 39.1 °C (102.4 °F). Her qSOFA score is:

   1. A. 1
   2. B. 2
   3. C. 4
   4. D. 3
   Show answer

   Answer: D. 3

   qSOFA awards one point each for a respiratory rate of 22 or more, altered mentation, and a systolic pressure of 100 mmHg or less; she meets all three. The score has only three items, so 4 is impossible.

6. A 59-year-old with pneumonia still has a MAP of 58 mmHg after 30 mL/kg of crystalloid, and her lactate is 5 mmol/L. She meets the definition of:

   1. A. Sepsis without shock
   2. B. Septic shock
   3. C. Hypovolemic shock
   4. D. Cardiogenic shock
   Show answer

   Answer: B. Septic shock

   Septic shock is sepsis with hypotension requiring vasopressors to keep a MAP of 65 mmHg or more and a lactate above 2 mmol/L despite adequate fluid. She needs norepinephrine; calling it sepsis without shock understates her risk of death.

7. A 34-year-old woman ate shrimp and now has diffuse hives, wheezing, throat tightness, and a BP of 78/40 mmHg. The underlying cause of her hypotension is:

   1. A. Loss of sympathetic tone from a spinal injury
   2. B. Pump failure from an acute myocardial infarction
   3. C. Obstruction of venous return by trapped air
   4. D. Mediator-induced vasodilation and capillary leak
   Show answer

   Answer: D. Mediator-induced vasodilation and capillary leak

   Mast cells and basophils release histamine and other mediators that dilate vessels and make capillaries leak, causing relative and absolute hypovolemia. Loss of sympathetic tone defines neurogenic shock, which requires a cord injury.

8. Anaphylaxis is highly likely when, minutes to hours after exposure to a likely allergen, a patient develops:

   1. A. Hypotension or bronchospasm, even without hives
   2. B. Hives on the arms and face without other symptoms
   3. C. Nausea alone that resolves after 20 minutes
   4. D. A localized area of swelling at a sting site
   Show answer

   Answer: A. Hypotension or bronchospasm, even without hives

   Current criteria recognize anaphylaxis when a known or likely allergen is followed by hypotension or respiratory compromise, even without skin involvement. Isolated hives or a local reaction does not meet the criteria.

9. A 19-year-old with a C6 cord injury from a shallow-water dive has BP 82/50 mmHg and HR 50. Besides hypotension, which problem is this patient most likely to develop?

   1. A. Hypertension from pain-induced catecholamines
   2. B. Heat loss from inability to vasoconstrict
   3. C. Severe tachycardia from the cord injury
   4. D. Rapid fluid loss through the warm, dry skin
   Show answer

   Answer: B. Heat loss from inability to vasoconstrict

   Loss of sympathetic tone below a high cord injury prevents vasoconstriction and shivering, so the patient takes on the temperature of the environment and must be kept warm. The heart rate is slow, not fast, because vagal tone is unopposed.

10. A 35-year-old pulled from a car fire has 30% TBSA burns and is hypotensive 20 minutes after the injury. You should suspect:

    1. A. Expected burn shock from early plasma loss
    2. B. Pain causing a brief vasovagal reaction
    3. C. Another cause, such as bleeding or cyanide
    4. D. Fluid overload from the heat of the fire
    Show answer

    Answer: C. Another cause, such as bleeding or cyanide

    Burn shock develops over hours as capillary leak builds, so hypotension within the first hour after a burn is not expected from the burn itself. It should prompt a search for another cause: hemorrhage from the crash, cyanide or carbon monoxide from smoke, or a spinal injury. Assuming burn shock delays control of a hidden bleed. A vasovagal faint is brief and would not explain sustained hypotension in a burned crash victim. Heat does not cause fluid overload; burns cause fluid loss.

11. An 82-year-old on furosemide has eaten and drunk little for a week. She is dizzy, HR 106, BP 90/58 mmHg, with dry mucosa, clear lungs, and flat neck veins. The most likely type of shock is:

    1. A. Cardiogenic, from a failing older heart muscle
    2. B. Hypovolemic, from diuretics and poor intake
    3. C. Distributive, from an early hidden infection
    4. D. Obstructive, from a pulmonary embolism
    Show answer

    Answer: B. Hypovolemic, from diuretics and poor intake

    Diuretic use with poor intake, dry mucosa, flat neck veins, and clear lungs point to hypovolemic shock; she needs fluid, given in small, reassessed boluses because older hearts tolerate overload poorly. Cardiogenic shock usually brings crackles or distended neck veins, which she does not have. Distributive shock from infection would usually come with fever or a source and warm skin early. A pulmonary embolism causes obstructive shock with distended neck veins and sudden dyspnea, not a week of poor intake.

12. Cardiogenic shock is most commonly caused by:

    1. A. Severe dehydration that reduces the preload to the heart
    2. B. A tension pneumothorax that compresses the vena cava
    3. C. An anaphylactic reaction that dilates the coronary arteries
    4. D. Acute MI with loss of left ventricular muscle
    Show answer

    Answer: D. Acute MI with loss of left ventricular muscle

    Loss of about 40% or more of left ventricular myocardium from an infarction is the leading cause of cardiogenic shock. Tension pneumothorax causes obstructive shock by blocking venous return, not by damaging the pump.

13. A 68-year-old woman has chest pain, ST elevation, and a BP of 80/50 mmHg minutes after learning of her husband's sudden death. At the cath lab her coronary arteries are open. The most likely cause is:

    1. A. Coronary vasospasm from cocaine use
    2. B. Hemorrhagic shock from occult bleeding
    3. C. Stress (takotsubo) cardiomyopathy
    4. D. Panic attack with a false-positive ECG
    Show answer

    Answer: C. Stress (takotsubo) cardiomyopathy

    A surge of catecholamines after severe emotional or physical stress can stun the left ventricle, causing chest pain, ST changes, and even cardiogenic shock with open coronary arteries. It usually recovers over weeks. A panic attack does not cause ST elevation or shock, and nothing here suggests stimulant use or bleeding.

14. A patient with an inferior MI is hypotensive with clear lung sounds and distended neck veins. The most likely cause is:

    1. A. Right ventricular infarction
    2. B. Left ventricular pump failure
    3. C. Hemorrhagic shock
    4. D. Tension pneumothorax
    Show answer

    Answer: A. Right ventricular infarction

    Right ventricular infarction, which often accompanies inferior MI, causes hypotension with clear lungs and JVD because the right ventricle cannot push blood through the lungs. Left ventricular failure would cause crackles.

15. A 50-year-old with suspected massive PE is hypotensive with distended neck veins and clear lungs. After 500 mL of fluid he is no better. Large further boluses are avoided because they can:

    1. A. Overload the left ventricle and cause pulmonary edema
    2. B. Trigger a vagal reflex that slows the heart
    3. C. Overstretch the right ventricle, lowering output
    4. D. Speed up clot breakdown and cause bleeding
    Show answer

    Answer: C. Overstretch the right ventricle, lowering output

    In massive PE the right ventricle is already dilated against a high afterload. A modest bolus (about 500 mL) can help, but more volume overstretches it, pushes the septum into the left ventricle, and reduces left-sided filling and output, so further support is with a vasopressor such as norepinephrine while reperfusion is arranged. The left ventricle in massive PE is underfilled, not overloaded, so pulmonary edema is not the concern. Fluid does not trigger a vagal reflex or speed clot breakdown; the problem is a failing, overdistended right heart.

16. A 28-year-old with a suspected ruptured ectopic pregnancy is pale and confused, with a BP of 76/40 mmHg but a heart rate of only 72. You should:

    1. A. Suspect neurogenic shock from a hidden spine injury
    2. B. Treat it as hemorrhagic shock despite the rate
    3. C. Assume the low pressure is a cuff error
    4. D. Attribute her confusion to a simple faint
    Show answer

    Answer: B. Treat it as hemorrhagic shock despite the rate

    Hypotension with pallor and confusion in a woman with a suspected ruptured ectopic is hemorrhagic shock until proven otherwise. Some patients with intraperitoneal bleeding have a normal or even slow heart rate (relative bradycardia, thought to be a vagal response to blood in the abdomen), and beta-blockers or fitness can do the same, so a normal rate must not reassure you. Neurogenic shock needs a cord injury, which nothing suggests. A low pressure with pallor and confusion should be acted on, not dismissed as a cuff error. A simple faint resolves quickly when the patient is supine and does not leave persistent hypotension and confusion.

17. In which type of shock is a quick procedure, rather than fluid or drugs, most likely to reverse the hypotension almost at once?

    1. A. Obstructive, as in a tension pneumothorax
    2. B. Hypovolemic, as in severe vomiting
    3. C. Distributive, as in septic shock
    4. D. Cardiogenic, as in a large anterior wall MI
    Show answer

    Answer: A. Obstructive, as in a tension pneumothorax

    Obstructive shock comes from a mechanical block to filling or outflow, so relieving it, with needle decompression for tension pneumothorax or pericardiocentesis for tamponade, can restore output within moments. Hypovolemic shock from vomiting needs volume over time. Septic shock needs fluid, vasopressors, antibiotics, and source control. Cardiogenic shock from an MI needs revascularization and pressor or mechanical support, which take far longer than a field procedure.

18. A 58-year-old woman with lung cancer has a week of worsening dyspnea, JVD, a BP of 84/66 mmHg, and low-voltage QRS complexes that alternate in height. The type of shock is:

    1. A. Cardiogenic
    2. B. Distributive
    3. C. Hypovolemic
    4. D. Obstructive
    Show answer

    Answer: D. Obstructive

    A malignant pericardial effusion causing tamponade restricts ventricular filling, a mechanical (obstructive) cause; electrical alternans reflects the heart swinging in the fluid. Her heart muscle is not primarily failing, so this is not cardiogenic shock, and pericardiocentesis is the definitive treatment.

19. A 75-year-old with 3 days of vomiting and a tense, distended abdomen is in shock, though she has vomited only small amounts. Most of her lost volume is likely in the:

    1. A. Skin, lost as sweat from the fever
    2. B. Bowel wall and lumen, as third-spaced fluid
    3. C. Lungs, as fluid in the alveoli
    4. D. Bladder, held there by acute urinary retention
    Show answer

    Answer: B. Bowel wall and lumen, as third-spaced fluid

    In a bowel obstruction, large volumes of fluid collect in the distended bowel and its swollen wall and leak into the peritoneum. This fluid is outside the circulation (third-spaced), so the patient can be severely hypovolemic with little visible loss; she needs isotonic fluid in reassessed boluses and surgical evaluation. Sweating from fever loses some water but not enough to explain shock. Pulmonary edema would cause crackles and hypoxia and does not explain hypovolemia. Retained urine is still not lost volume, and retention does not cause shock.

20. Six hours after a cardiac catheterization through the right femoral artery, a 70-year-old on heparin has right flank and back pain, HR 124, and BP 84/50 mmHg. The groin site looks dry. You should suspect:

    1. A. A kidney stone triggered by the contrast dye
    2. B. An allergic reaction to the contrast agent
    3. C. Retroperitoneal bleeding from the puncture
    4. D. A new heart attack causing cardiogenic shock
    Show answer

    Answer: C. Retroperitoneal bleeding from the puncture

    A femoral puncture can bleed backward into the retroperitoneal space, where large volumes collect with little or no visible bleeding at the groin, especially in patients on anticoagulants. Back or flank pain with signs of shock after femoral access suggests hemorrhagic shock; treat it as such and transport promptly.

21. A 22-year-old who had a viral illness last week now has dyspnea, HR 132, BP 82/56 mmHg, crackles, JVD, and cool skin. The most likely type of shock is:

    1. A. Cardiogenic, from inflamed heart muscle
    2. B. Septic, from a lingering viral infection
    3. C. Hypovolemic, from poor intake while ill
    4. D. Anaphylactic, from a medicine he took
    Show answer

    Answer: A. Cardiogenic, from inflamed heart muscle

    Crackles and JVD with hypotension and cool skin point to pump failure, and in a young adult after a viral illness, myocarditis is a leading cause; fulminant myocarditis can progress quickly and may need mechanical support, so a center with cardiac critical care is the right destination. Sepsis usually causes warm skin early and flat neck veins. Hypovolemia causes flat neck veins and clear lungs. Anaphylaxis follows an exposure and usually brings hives, bronchospasm, or both, not crackles with JVD.

22. A 30-year-old who fell 20 feet has paraplegia from a T12 cord injury, HR 124, BP 84/50 mmHg, and cool, pale skin. His hypotension is most likely due to:

    1. A. Neurogenic shock from loss of sympathetic tone
    2. B. Spinal shock with a loss of the cord reflexes
    3. C. Pain and anxiety from the spinal fracture
    4. D. Bleeding, since the injury is too low for it
    Show answer

    Answer: D. Bleeding, since the injury is too low for it

    Neurogenic shock needs a cord injury high enough (above about T6) to cut most sympathetic outflow, and it causes a slow or normal heart rate with warm skin. A T12 injury is too low, and his tachycardia and cool, pale skin are the signs of hemorrhage, which a 20-foot fall makes likely (pelvis, abdomen, retroperitoneum). Spinal shock is a temporary loss of cord reflexes below the injury, not a cause of hypotension. Pain and anxiety do not produce a pressure of 84/50 with cool skin.

23. Toxic shock syndrome, associated with tampon use or packed wounds, is a form of:

    1. A. Obstructive shock
    2. B. Distributive shock
    3. C. Cardiogenic shock
    4. D. Neurogenic shock
    Show answer

    Answer: B. Distributive shock

    Bacterial toxins trigger a massive inflammatory response with vasodilation and capillary leak, producing distributive shock with fever, rash, and multiorgan involvement. It is not caused by obstruction or pump failure.

24. A patient is in shock with clear lungs, flat neck veins, and warm, flushed skin with a wide pulse pressure. The most likely category is:

    1. A. Cardiogenic shock
    2. B. Obstructive shock
    3. C. Distributive shock
    4. D. Hemorrhagic shock
    Show answer

    Answer: C. Distributive shock

    Warm skin and a wide pulse pressure reflect vasodilation, the hallmark of distributive shock. Hemorrhagic shock causes cool, pale skin with a narrow pulse pressure from vasoconstriction.

25. A patient can have more than one type of shock at once. Which example combines two types?

    1. A. A dehydrated child who has lost fluid from vomiting and diarrhea
    2. B. A ventilated patient with an isolated tension pneumothorax
    3. C. An adult with a stab wound that is bleeding externally
    4. D. A burned trauma patient who is also bleeding internally
    Show answer

    Answer: D. A burned trauma patient who is also bleeding internally

    Mixed shock is common: a burned trauma patient loses plasma through leaky capillaries and may also be hemorrhaging, so both hypovolemic mechanisms (and sometimes others) act at once. A dehydrated child has a single hypovolemic mechanism. An isolated tension pneumothorax is purely obstructive. A stab wound bleeding externally is purely hemorrhagic. Recognizing mixed shock matters because treating only one mechanism leaves the other uncorrected.