A nurse is caring for a patient with disseminated intravascular coagulation (DIC). Which nursing diagnosis should not be included in this patient’s plan of care?

Fluid imbalance associated with excessive blood component replacement

Risk for impaired skin integrity associated with ischemia or bleeding

Risk for hypervolemia associated with bleeding

Anxiety associated with uncertain prognosis and risk for death

Answer and Explanation

The Correct Answer is C

Choice A reason: Fluid imbalance is appropriate, as DIC involves bleeding and clotting, requiring blood component replacement (e.g., platelets, plasma). This can disrupt fluid balance, causing hypovolemia from bleeding or overload from transfusions. Monitoring and managing fluid status is critical to prevent complications like shock or edema in DIC patients.

Choice B reason: Risk for impaired skin integrity is relevant, as DIC causes microthrombi, leading to tissue ischemia, and bleeding, causing bruising or petechiae. These increase the risk of skin breakdown, especially in prolonged immobility. This diagnosis addresses potential complications from DIC’s vascular and hemorrhagic effects, requiring skin monitoring and care.

Choice C reason: Risk for hypervolemia associated with bleeding is incorrect, as bleeding in DIC causes hypovolemia, not hypervolemia. Fluid overload may occur from excessive transfusions, but bleeding itself reduces volume. This diagnosis is inaccurate, as DIC’s primary fluid issue is loss, not excess, making it inappropriate for the care plan.

Choice D reason: Anxiety is a valid diagnosis in DIC due to its life-threatening nature and uncertain prognosis. Patients may experience fear from bleeding, organ failure risks, or hospitalization. Addressing anxiety through support and communication is appropriate, as it impacts psychological well-being and coping during this critical illness, supporting holistic care.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Decreased mentation is a DIC symptom, as microthrombi impair cerebral perfusion, and bleeding may cause hypovolemia, reducing oxygen delivery to the brain. Hypoxia and metabolic disturbances from organ dysfunction further contribute to confusion or altered consciousness, making this a key clinical sign of severe DIC.

Choice B reason: Increased urine output is not typical in DIC. Microthrombi and hypovolemia from bleeding reduce renal perfusion, leading to oliguria or acute kidney injury. Increased urine output occurs in conditions like diabetes insipidus, not DIC, where renal compromise is common due to microvascular clotting and shock.

Choice C reason: Fever is common in DIC, often due to underlying triggers like sepsis or inflammation, which activate the clotting cascade. Cytokine release in these conditions elevates body temperature. Fever reflects the systemic inflammatory response, making it a frequent symptom in DIC, especially when infection is the precipitating cause.

Choice D reason: Dyspnea occurs in DIC due to pulmonary microthrombi impairing gas exchange, leading to hypoxia. Hemorrhage into alveoli or pulmonary edema from organ dysfunction may also contribute. Respiratory distress is a critical symptom, reflecting lung involvement in DIC’s microvascular clotting, requiring urgent intervention to restore oxygenation.

Choice E reason: Six-second capillary refill indicates poor perfusion, common in DIC due to hypovolemia from bleeding and microthrombi obstructing peripheral circulation. Prolonged refill reflects shock or vascular compromise, a key sign of DIC’s systemic impact, necessitating immediate treatment to address coagulopathy and restore hemodynamic stability.

A. NSTEMI B. Myxedema C. SIADH D. Thyroid storm crisis

Correct Answer is B

Explanation

Choice A reason: NSTEMI (non-ST-elevation myocardial infarction) is a heart attack caused by coronary artery occlusion, leading to myocardial ischemia. Symptoms include chest pain and elevated cardiac enzymes, not bradycardia, hyponatremia, or altered consciousness. Hypothyroidism does not directly cause NSTEMI, and these symptoms align with metabolic, not cardiac, pathology.

Choice B reason: Myxedema coma is a life-threatening complication of severe hypothyroidism, characterized by bradycardia, hyponatremia, hypotension, altered consciousness, and respiratory depression. Hypothyroidism slows metabolism, leading to fluid retention, low sodium, and reduced cardiac output. These symptoms match the patient’s presentation, making myxedema coma the most likely diagnosis in this scenario.

Choice C reason: SIADH causes hyponatremia due to excessive antidiuretic hormone, leading to water retention. However, it does not typically cause bradycardia, hypotension, or respiratory difficulty. SIADH is not a complication of hypothyroidism, and the patient’s symptoms, including altered consciousness, align more closely with myxedema coma than SIADH’s water imbalance.

Choice D reason: Thyroid storm is a life-threatening hyperthyroidism complication, presenting with tachycardia, hyperthermia, and agitation. The patient’s bradycardia, hypotension, and hyponatremia are opposite to thyroid storm’s hypermetabolic state. Hypothyroidism leads to myxedema coma, not thyroid storm, making this choice inconsistent with the patient’s clinical presentation and lab findings.

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A nurse is caring for a patient with disseminated intravascular coagulation (DIC). Which nursing diagnosis should not be included in this patient’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to educate a group of students on the signs and symptoms of disseminated intravascular coagulation (DIC). The nurse knows that teaching was effective when the students are able to recognize which symptoms as being associated with DIC? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

A patient presents with bradycardia, low serum sodium, a blood pressure of 86/54 mmHg, decreased level of consciousness, and difficulty breathing. His labs support severe hypothyroidism. Which life-threatening complication is he likely experiencing?

Correct Answer is B

Explanation

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