A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Administer aspirin daily as ordered

Place a pressure-reducing mattress on the client’s bed

Administer meperidine (Demerol) intramuscularly as needed for pain

Provide mouth care every 4 hours with lemon-glycerin swabs

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Administering aspirin is contraindicated in DIC, as it inhibits platelet function, worsening bleeding risk in a condition already characterized by thrombocytopenia and coagulopathy. Aspirin’s antiplatelet effect could exacerbate hemorrhage, making it an inappropriate intervention for a client with active DIC-related bleeding tendencies.

Choice B reason: Placing a pressure-reducing mattress is appropriate in DIC to prevent skin breakdown, as clients are at risk for bleeding and bruising due to low platelets and coagulopathy. Immobility from critical illness increases pressure injury risk, and a specialized mattress minimizes tissue damage and supports skin integrity.

Choice C reason: Administering meperidine intramuscularly is inappropriate in DIC, as intramuscular injections can cause hematomas due to low platelets and impaired clotting. Pain management in DIC should use intravenous or oral routes to avoid bleeding complications, making this intervention unsafe for the client’s condition.

Choice D reason: Lemon-glycerin swabs for mouth care are not ideal in DIC, as they can dry mucous membranes, increasing bleeding risk in thrombocytopenic clients. Gentle oral care with saline or soft brushes is preferred to maintain mucosal integrity, making this intervention less appropriate for DIC management.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Infection is not directly related to tissue hypoxia in iron deficiency anemia. Hypoxia results from low hemoglobin, reducing oxygen delivery, but it does not inherently cause infection. Infections may contribute to anemia in chronic disease but are not the primary issue in iron deficiency.

Choice B reason: Deficient fluid volume is not a primary concern in iron deficiency anemia. Impaired erythropoiesis reduces red blood cell production due to low iron, causing anemia, but fluid volume remains normal unless bleeding occurs. Fatigue from low oxygen capacity is more directly linked to the condition.

Choice C reason: Acute pain is not typical in iron deficiency anemia. Pain is associated with hemolytic anemias like sickle cell disease due to vaso-occlusion. Iron deficiency causes fatigue and dyspnea from low hemoglobin, not hemolysis or pain, making this an incorrect association.

Choice D reason: Fatigue related to decreased oxygen-carrying capacity is the most likely issue in iron deficiency anemia. Low iron impairs hemoglobin synthesis, reducing red blood cell oxygen transport, causing tissue hypoxia and fatigue, especially during exertion, directly reflecting the pathophysiology of the client’s condition.

A. Addison disease B. Hashimoto disease C. Cushing syndrome D. Graves disease

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Addison disease results from adrenal insufficiency, causing deficient cortisol and aldosterone production. This leads to symptoms like hypotension, hyponatremia, and hyperkalemia, opposite to the cortisol excess seen in Cushing syndrome, which involves weight gain, hypertension, and hyperglycemia due to elevated adrenal cortex activity.

Choice B reason: Hashimoto disease is an autoimmune thyroiditis causing hypothyroidism, with low thyroid hormone levels leading to fatigue, weight gain, and cold intolerance. It does not involve adrenal cortex cortisol excess, unlike Cushing syndrome, which is characterized by hypercortisolism and distinct metabolic and physical symptoms.

Choice C reason: Cushing syndrome is defined by excess free circulating cortisol from the adrenal cortex, due to pituitary tumors, adrenal hyperplasia, or exogenous steroids. This causes weight gain, moon face, hypertension, and hyperglycemia, reflecting cortisol’s effects on metabolism, fat distribution, and fluid balance, making it the correct disorder.

Choice D reason: Graves disease is an autoimmune condition causing hyperthyroidism, with excess thyroid hormone leading to weight loss, tachycardia, and heat intolerance. It does not involve adrenal cortex cortisol production, unlike Cushing syndrome, which is specifically related to hypercortisolism and its systemic metabolic effects.

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A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client has been diagnosed with iron deficiency anemia. Which is most likely based on this client’s health status?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

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