A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Activation of complement pathways.

Inhibition of red blood production.

Production of extra platelets.

Depletion of clotting factors.

Answer and Explanation

The Correct Answer is D

Rationale

A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.

B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.

C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.

D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.

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Correct Answer is B

Explanation

Rationale

A. Repositioning the stethoscope or reinflating the cuff may be necessary if the sounds are unclear or if there is difficulty in hearing the Korotkoff sounds, but these actions come after noting any auscultatory gap.

B. It's characterized by a period of silence between the appearance and disappearance of sounds. Noting its presence is important for accurately recording the blood pressure readings, as failure to recognize an auscultatory gap could lead to underestimating the systolic pressure.

C. After repositioning the stethoscope or noting the presence of an auscultatory gap, the nurse should proceed with the blood pressure assessment.

D. If the cuff was not inflated adequately during the initial inflation, the nurse may not have occluded the artery completely, leading to inaccurate readings. However, in this scenario where Korotkoff sounds

are heard, it indicates that the cuff pressure was sufficient to occlude and then release the artery's blood flow.

A. Select foods that are lower in caloric density B. Increase exercise intensity C. Get up and walk at least once an hour at work D. Add healthy foods to increase caloric intake E. Avoid food with high carbohydrate levels

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A. Select foods that are lower in caloric density
Effective: Choosing foods that are lower in caloric density (such as fruits, vegetables, lean proteins) can help the client feel fuller with fewer calories. This can support weight maintenance or even weight loss if that is the goal.

B. Increase exercise intensity
Effective: Increasing exercise intensity can help the client burn more calories, contributing to energy expenditure. This can assist in achieving energy balance, particularly if the client wants to maintain her current weight while consuming adequate calories.

C. Get up and walk at least once an hour at work
Effective: Incorporating regular physical activity throughout the day, such as walking breaks, helps increase energy expenditure. It also breaks up sedentary behavior, which is beneficial for overall health and can contribute to energy balance.

D. Add healthy foods to increase caloric intake
Ineffective: Adding healthy foods to increase caloric intake would likely lead to a positive energy balance (where intake exceeds expenditure), potentially causing weight gain. Since the goal is to maintain weight, increasing caloric intake, even with healthy foods, would not be effective.

E. Avoid food with high carbohydrate levels
Ineffective: Carbohydrates are an important source of energy. Avoiding foods with high carbohydrate levels could limit the client's energy intake, potentially leading to negative energy balance if not replaced adequately with other nutrients.

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A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

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