The nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
Xerostomia
Bradycardia
Epistaxis
Hypertension
The Correct Answer is C
A. Xerostomia: Dry mouth, not typically associated with DIC.
B. Bradycardia: Not typically seen in DIC; usually, there is tachycardia due to the underlying condition.
C. Epistaxis. Epistaxis is a common physical finding in DIC due to bleeding tendencies. DIC leads to consumption of clotting factors and platelets, resulting in bleeding manifestations like epistaxis.
D. Hypertension: Hypotension is more common due to widespread clotting and bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Coma: Possible in severe cases but not universally anticipated.
B. Hypothermia: Incorrect. Thyroid storms typically causes hyperthermia, not hypothermia.
C. Tachycardia. Tachycardia is a hallmark of thyroid storms due to excessive thyroid hormone levels stimulating the heart. Increased metabolic rate and sympathetic activity lead to rapid heart rate.
D. Fruity smelling breath: Not typically associated with thyroid storm.
Correct Answer is A
Explanation
A. Lethality of the method and availability of means. Assessing the method and means helps determine the immediacy and seriousness of the threat. Knowing the lethality of the method and whether the means are readily available informs the level of intervention needed to keep the client safe.
B. Client's educational and economic background: While socioeconomic factors can influence mental health, they are not immediate priorities in a suicidal crisis.
C. Client's insight into the reasons for the decision: Insight is important for understanding motivations but is secondary to immediate safety concerns.
D. Quality of the client's social support: Social support is crucial but is secondary to assessing imminent risk of harm.
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