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 D

Explanation

Reasoning:

Choice A reason: Bundle branch block affects ventricular conduction but does not typically cause emboli. It may lead to dyssynchrony but lacks the stasis in the atria that promotes clot formation, making it less associated with cardiogenic embolic strokes compared to atrial fibrillation’s thrombus-forming mechanism.

Choice B reason: Ventricular tachycardia is a life-threatening arrhythmia affecting the ventricles, causing hemodynamic instability but not typically embolic strokes. It does not promote atrial stasis or clot formation, which are necessary for cardiogenic emboli to travel to the brain, unlike atrial fibrillation.

Choice C reason: Supraventricular tachycardia causes rapid heart rates above the ventricles but is less likely to form atrial clots than atrial fibrillation. It does not typically cause the prolonged stasis needed for thrombus formation, making it less associated with embolic strokes in the brain.

Choice D reason: Atrial fibrillation is strongly associated with cardiogenic embolic strokes. It causes irregular atrial contractions, leading to blood stasis in the atria, promoting thrombus formation. These clots can embolize to the brain, causing ischemic stroke, making it a key risk factor requiring anticoagulation.

A. Dry mucous membranes B. Weight gain C. Poor skin turgor D. Hypotension E. Decreased heart rate

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

Explanation

Reasoning:

Choice A reason: Dry mucous membranes support diabetes insipidus, as excessive water loss from polyuria due to ADH deficiency causes dehydration. This reduces moisture in mucosal tissues, leading to dryness in the mouth and throat, a common physical finding in dehydrated states associated with uncontrolled diabetes insipidus.

Choice B reason: Weight gain is not consistent with diabetes insipidus, which causes water loss through polyuria, leading to dehydration and potential weight loss. Weight gain is more typical of conditions like SIADH, where water retention increases body fluid volume, diluting sodium and causing hyponatremia.

Choice C reason: Poor skin turgor is a sign of dehydration, supporting diabetes insipidus. ADH deficiency leads to excessive dilute urine output, reducing body water content. This causes skin to lose elasticity, as subcutaneous tissues become dehydrated, making poor skin turgor a key physical finding in this condition.

Choice D reason: Hypotension is a clinical sign of diabetes insipidus due to hypovolemia from excessive water loss. Reduced blood volume decreases blood pressure, as the cardiovascular system struggles to maintain perfusion. This finding supports the nurse’s suspicion, as dehydration from polyuria is a hallmark of the condition.

Choice E reason: Decreased heart rate, or bradycardia, is not typical in diabetes insipidus. Dehydration from polyuria typically causes tachycardia as the heart compensates for reduced blood volume. A decreased heart rate may indicate another condition but does not support the diagnosis of diabetes insipidus in this context.

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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

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Correct Answer is D

Explanation

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

Explanation

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