Exhibits
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According to the lab values, the client has
The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"H","dropdown-group-3":"D"}
Rationale for Correct Choices:
- Anemia: The lab values indicate that the client’s hemoglobin and hematocrit are lower than normal, suggesting anemia. Anemia in this case is likely due to blood loss from the trauma, as the client has internal hemorrhaging, with blood noted in the peritoneum.
- Blood loss: The client’s abdominal trauma, with liver and spleen lacerations and blood in the peritoneum, is a clear indicator of significant internal bleeding. This blood loss is directly responsible for the anemia seen in the lab results.
- Hemodilution from intravenous fluids: The client is receiving IV fluids at a rate of 100 mL/hr, which can dilute the blood and artificially lower hematocrit and hemoglobin levels. This is a common effect when fluids are given in large amounts, as the fluid increases plasma volume without immediately increasing red blood cells.
Rationale for Incorrect Choices:
- Acidosis: Acidosis typically presents with changes in blood pH and respiratory or renal compensation, which is not indicated by the client's lab results or current status. There are no signs of metabolic or respiratory acidosis in the current clinical picture.
- Rh factor sensitization: Rh factor sensitization usually occurs during pregnancy when Rh-negative mothers develop antibodies against Rh-positive fetal blood cells. This is unrelated to the client’s trauma and lab findings, which focus on anemia.
- Hypovolemia: Hypovolemia is more directly related to the blood loss and the hemodilution effect from intravenous fluid administration, making it a contributing but less specific factor in the anemia diagnosis.
- Disseminated intravascular coagulation (DIC): DIC is characterized by widespread clotting followed by bleeding. There is no evidence of abnormal clotting or bleeding issues in the lab results or clinical presentation, such as abnormal coagulation studies.
- Pregnancy: Pregnancy is not applicable in this case as the client's history does not mention any signs or symptoms of pregnancy. Anemia in this patient is related to trauma-induced blood loss and subsequent hemodilution, not pregnancy-related causes.
- Clotting cascade: While it is relevant to conditions like DIC or bleeding disorders, it does not directly explain the client's low hemoglobin or hematocrit. The lab results are more consistent with blood loss and fluid resuscitation.
- Blood administration: There is no mention of the client receiving blood products. While blood transfusion might be needed given the blood loss, there is no current indication from the lab results that blood administration has occurred or is required at this point.
- Immune response: An immune response is typically seen in infections or allergic reactions. The client’s current clinical condition and lab results do not suggest an infection or immune response but rather trauma-related blood loss and fluid effects.
- Hypoventilation: Hypoventilation typically leads to respiratory acidosis or elevated CO2 levels, but the client is intubated and on mechanical ventilation, with no indication of respiratory distress or acidosis.
- Hypoxia: Although trauma patients may experience hypoxia, the client’s oxygen saturation is 100%, and there is no indication of respiratory distress or hypoxia in the lab results. The anemia is more related to blood loss rather than a lack of oxygen in the tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hydrocortisone: Addison’s disease is characterized by insufficient cortisol production. The client’s symptoms, including weakness, confusion, and dehydration, along with laboratory values indicating low sodium, low glucose, and elevated potassium, suggest an adrenal crisis. Hydrocortisone is the primary.
B. Regular insulin: Regular insulin is used to lower blood glucose levels, but the client’s glucose level is already low, not high. Insulin could worsen the client's hypoglycemia. The focus should be on correcting the cortisol deficiency rather than administering insulin.
C. Broad spectrum antibiotic: While antibiotics may be needed if there’s a concern for infection, there’s no evidence of active infection here. The priority is addressing the client's Addisonian crisis, which is primarily treated with hydrocortisone, not antibiotics.
D. Potassium chloride: The client's potassium is elevated (5.3 mEq/L), but potassium chloride is not indicated in this case. The priority is to manage the underlying adrenal crisis, which will address the electrolyte imbalance.
Correct Answer is A
Explanation
A. Heart rate 100 beats/minute: A compensatory increase in heart rate (tachycardia) is expected in orthostatic hypotension. It helps maintain cerebral perfusion when blood pools in the lower extremities after standing quickly.
B. Blood pressure 125/65 mm Hg: This BP shows a slight systolic increase, which is not typical after orthostatic stress. A decrease in BP, not an increase, would be expected if symptoms like dizziness are present.
C. Heart rate 70 beats/minute: A decreased heart rate is not physiologically expected when someone experiences postural hypotension. Bradycardia would worsen cerebral perfusion and is inconsistent with dizziness.
D. Blood pressure 115/70 mm Hg: This change is too minor to explain dizziness. In orthostatic hypotension, we usually expect a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic after position change.
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