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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Reasoning:

Choice A reason: Frequent urination may occur in Cushing’s syndrome due to hyperglycemia-induced osmotic diuresis, but it is not immediately life-threatening. It reflects chronic metabolic changes rather than an acute emergency, so it is less urgent than an irregular pulse, which could indicate a cardiovascular crisis.

Choice B reason: An irregular apical pulse is critical to report immediately in Cushing’s syndrome, as cortisol excess increases cardiovascular risk, including arrhythmias like atrial fibrillation. Irregular pulses may indicate acute cardiac instability, requiring urgent intervention to prevent complications like stroke or heart failure in this high-risk population.

Choice C reason: Dry mucous membranes may suggest dehydration but are not typical in Cushing’s syndrome, which causes fluid retention. Even if present, they are less urgent than an irregular pulse, as dehydration can be managed with fluids, whereas cardiac arrhythmias pose an immediate threat requiring prompt attention.

Choice D reason: Pitting edema in the legs is common in Cushing’s syndrome due to cortisol’s mineralocorticoid effects causing fluid retention. While important, it is a chronic issue manageable with diuretics and not as immediately life-threatening as an irregular pulse, which could indicate acute cardiac complications.

A. I have a difficult time falling asleep at night B. I have difficulty breathing when walking 30 feet C. I have an increase in my appetite D. I feel hot all of the time

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Difficulty falling asleep is not a specific symptom of iron deficiency anemia. While fatigue is common, it affects energy levels, not sleep onset. Insomnia may result from other causes like anxiety or neurological conditions, not the reduced oxygen-carrying capacity of iron deficiency anemia.

Choice B reason: Difficulty breathing when walking 30 feet, or exertional dyspnea, is a hallmark of iron deficiency anemia. Low hemoglobin reduces oxygen delivery to tissues, causing shortness of breath during activity as the body struggles to meet oxygen demands, making this a key subjective symptom.

Choice C reason: Increased appetite is not typical in iron deficiency anemia. Some patients experience pica, craving non-food items, but not increased food appetite. Anemia causes fatigue and weakness, not hunger, which is more associated with metabolic or endocrine disorders, not iron deficiency.

Choice D reason: Feeling hot all the time is not a symptom of iron deficiency anemia. Patients often feel cold due to reduced oxygen delivery impairing thermoregulation. Feeling hot suggests hyperthyroidism or infection, not the hypoxic or circulatory issues characteristic of iron deficiency anemia.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the health care provider immediately?

Correct Answer is B

Explanation

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

Correct Answer is B

Explanation

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?

A client comes to the clinic reporting fatigue. Laboratory findings reveal a low serum iron level, a low transferrin saturation, and a low ferritin level. Which type of anemia does the nurse suspect that correlates with these laboratory findings?

A client is brought by ambulance to the ED after experiencing what the family thinks is a stroke. The nurse caring for this client is aware that which is an absolute contraindication for thrombolytic therapy?

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

A nurse is assessing a client admitted with SIADH. What finding would the nurse expect to assess in a client with SIADH?

Which endocrine disorder causes the client to have dilutional hyponatremia?

A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?