A client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits:
Systolic blood pressure greater than 70 mm Hg
Stable level of consciousness
Urine output greater than or equal to 30 mL/hour
Decreased bleeding
The Correct Answer is D
Reasoning:
Choice A reason: Systolic blood pressure above 70 mm Hg is a goal in hypovolemia but is not the most specific outcome for DIC-related bleeding. While low blood pressure reflects fluid loss, addressing bleeding directly prevents further volume depletion, making reduced bleeding a more targeted and measurable outcome.
Choice B reason: A stable level of consciousness is important but not directly tied to deficient fluid volume from bleeding in DIC. Altered consciousness may result from cerebral ischemia or hyponatremia, but reducing bleeding is the primary goal to stabilize fluid volume and prevent further hemodynamic compromise.
Choice C reason: Urine output of 30 mL/hour or more indicates adequate renal perfusion but is a secondary outcome in DIC-related bleeding. While it reflects fluid status, directly addressing bleeding through interventions like transfusions or clotting factor replacement is more specific to correcting the underlying fluid volume deficit.
Choice D reason: Decreased bleeding is the most appropriate outcome for deficient fluid volume in DIC, as bleeding from mucosal and venipuncture sites directly causes volume loss. Reducing hemorrhage through platelet or factor replacement stabilizes fluid volume, preventing hypovolemia and its complications, making this the most measurable and relevant outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Antihypertensive treatment is not the priority for epidural hematoma, which causes rapid neurological deterioration from arterial bleeding and increased ICP. While hypertension may occur, surgical evacuation via burr holes is urgent to relieve pressure and prevent brain herniation, taking precedence over blood pressure management.
Choice B reason: Anticoagulant therapy is contraindicated in epidural hematoma, as it worsens bleeding. Epidural hematomas involve arterial hemorrhage, often from trauma, and anticoagulation would increase hematoma size, exacerbating ICP and neurological damage, making this an inappropriate and harmful intervention.
Choice C reason: Inserting an intracranial monitoring device may assess ICP but is not the priority in epidural hematoma. Rapid surgical intervention (burr holes) is needed to evacuate the hematoma and relieve life-threatening pressure, as monitoring delays critical treatment in this rapidly progressing condition.
Choice D reason: Burr holes are the priority intervention for epidural hematoma, a surgical emergency caused by arterial bleeding, often from skull trauma. Rapid evacuation of the hematoma relieves increased ICP, preventing brain herniation and death, making this the most urgent and effective treatment to stabilize the client.
Correct Answer is C
Explanation
Reasoning:
Choice A reason: A blood pressure of 150/90 mm Hg is not an absolute contraindication for thrombolytic therapy. While hypertension must be controlled (below 185/110 mm Hg) before thrombolytics, it is manageable with medication, unlike hemorrhagic stroke, which poses an immediate and absolute risk of worsening bleeding.
Choice B reason: Previous thrombolytic therapy within 12 months is not an absolute contraindication. Guidelines restrict thrombolytics within a shorter timeframe (e.g., recent major surgery), but prior therapy alone does not preclude use. Hemorrhagic stroke is a definitive contraindication due to the risk of catastrophic bleeding.
Choice C reason: Evidence of hemorrhagic stroke is an absolute contraindication for thrombolytic therapy, as thrombolytics like tPA dissolve clots, increasing bleeding in an already hemorrhagic brain. This risks worsening intracranial hemorrhage, leading to neurological deterioration or death, making it a critical exclusion criterion.
Choice D reason: Evidence of stroke evolution, such as progressing symptoms, is not an absolute contraindication. It may influence timing or eligibility, but thrombolytics can still be used within the time window if ischemic. Hemorrhagic stroke is a definitive barrier due to bleeding risk.
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