An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC?

A client with extensive burns

A client who has a diagnosis of acute respiratory distress syndrome

A client who suffered multiple trauma in a workplace accident

A client who is being treated for septic shock

Answer and Explanation

The Correct Answer is D

Reasoning:

Choice A reason: Extensive burns can trigger DIC through tissue damage and inflammation, releasing procoagulants that activate clotting. However, the risk is lower than in septic shock, as burns primarily cause localized injury, and systemic coagulopathy is less intense unless complicated by secondary infection or severe hypoperfusion.

Choice B reason: Acute respiratory distress syndrome (ARDS) may contribute to DIC through inflammation and hypoxia, but it is not the primary driver. ARDS affects lung function, and coagulopathy is secondary to underlying causes like sepsis, which has a more direct and potent effect on widespread clotting activation.

Choice C reason: Multiple trauma increases DIC risk through tissue injury and blood loss, activating coagulation pathways. However, septic shock has a higher risk due to systemic infection driving intense inflammatory and coagulative responses, consuming platelets and clotting factors more aggressively, leading to a greater likelihood of DIC.

Choice D reason: Septic shock poses the highest DIC risk, as systemic infection triggers massive cytokine release and endothelial damage, activating the coagulation cascade. This leads to widespread microthrombi, consuming platelets and clotting factors, causing both thrombosis and bleeding, making septic shock the most likely precipitant in ICU clients.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: Detecting infection via fever and tachycardia is important in sickle cell anemia, but auscultation of lungs and heart is not primarily for these signs. Fever is assessed by temperature, and tachycardia by pulse, not stethoscope. Auscultation focuses on organ-specific complications like respiratory or cardiac issues, not systemic signs.

Choice B reason: Dehydration can trigger sickle cell crises, but auscultation of lungs and heart does not directly assess hydration status. Fluid status is evaluated through vital signs, skin turgor, or urine output, not heart or lung sounds, making this response less accurate for the purpose of auscultation.

Choice C reason: Auscultating lungs and heart in sickle cell anemia detects abnormal sounds indicating acute respiratory complications, like acute chest syndrome, or heart failure from chronic anemia or vaso-occlusion. Crackles, wheezes, or murmurs suggest these complications, making this the most accurate explanation for the child’s question.

Choice D reason: Motor strength and stroke-related signs are assessed through neurological exams, not lung or heart auscultation. While stroke is a risk in sickle cell anemia due to vaso-occlusion, auscultation targets cardiopulmonary complications, not motor or neurological deficits, making this response inappropriate.

A. Frequent urination B. An irregular apical pulse C. Dry mucous membranes D. Pitting edema of the legs

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.

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An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be the best response by the nurse?

Correct Answer is C

Explanation

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

A nurse cares for several clients with anemia and notes that all the clients have different types of anemia. What is the nurse’s best understanding of how anemias are classified, based on the deficiency of erythrocytes? (Select all that apply)

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned that the co-worker may have?

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A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How can the nurse help the client manage potential sensory and perceptual difficulties?

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?