A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

"DIC is controllable with lifelong heparin usage."

"DIC is caused by abnormal coagulation involving fibrinogen."

"DIC is a genetic disorder involving a vitamin K deficiency."

"DIC is characterized by an elevated platelet count."

Answer and Explanation

The Correct Answer is B

A. "DIC is controllable with lifelong heparin usage": This statement is not accurate. While heparin may be used in the treatment of DIC, it is not a lifelong therapy, and the approach to treatment depends on the underlying cause.

B. "DIC is caused by abnormal coagulation involving fibrinogen": This is the correct answer. DIC is a condition characterized by widespread activation of the clotting cascade, leading to the formation of microthrombi throughout the body. Abnormal coagulation involves the consumption of clotting factors, including fibrinogen.

C. "DIC is a genetic disorder involving a vitamin K deficiency": This statement is not accurate. DIC is not a genetic disorder, and it is not primarily related to vitamin K deficiency. It is an acquired condition often associated with severe infections, sepsis, trauma, or other critical illnesses.

D. "DIC is characterized by an elevated platelet count": This statement is not accurate. In DIC, there is often a decrease in platelet count due to consumption and activation of platelets in the widespread formation of microthrombi.

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Correct Answer is C

Explanation

A. Impaired tissue perfusion: While impaired tissue perfusion is a concern in clients with varicose veins, the presence of ulcerations indicates that skin integrity is already compromised. Addressing impaired skin integrity is a more immediate concern.

B. Alteration in activity tolerance: Alteration in activity tolerance may be a consequence of impaired tissue perfusion and impaired skin integrity, but the priority is to address the current skin breakdown and prevent further complications.

C. Impaired skin integrity: This is the correct answer. The presence of varicose veins, ulcerations, and lower extremity edema indicates compromised skin integrity. The nurse should prioritize interventions to promote wound healing, prevent infection, and address the underlying causes contributing to impaired skin integrity.

D. Alteration in body image: While body image concerns may arise in clients with varicose veins, the immediate priority is addressing the physical complications such as impaired skin integrity to prevent further deterioration.

A. "I will take my diuretic before sleep and drink fluids during the day. B. I plan to slow down if I am tired the day after exercising." C. "I will read food labels and limit my sodium to 4 grams per day." D. "I should use naproxen to manage discomfort."

Correct Answer is B

Explanation

Correct answer: B

A. "I will take my diuretic before sleep and drink fluids during the day": This statement is not correct. Diuretics are usually taken in the morning to avoid disrupting sleep with increased urination at night. Additionally, fluid intake is generally restricted in congestive heart failure to manage fluid balance.

B. "I plan to slow down if I am tired the day after exercising":This statement reflects an understanding of the need to manage activity levels and recognize the signs of overexertion, which is crucial for clients with congestive heart failure. Pacing activities and allowing for adequate rest can help prevent exacerbations of heart failure symptoms.

C. "I will read food labels and limit my sodium to 4 grams per day": This is incorrect. Limiting sodium intake is a key component of heart failure management. The recommended sodium intake for individuals with heart failure is often much lower than 4 grams per day, typically around 2 grams or less.

D. "I should use naproxen to manage discomfort": Using nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen can contribute to fluid retention and worsen heart failure symptoms. This statement is not indicative of effective teaching.

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A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

Correct Answer is B

Explanation

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