The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and
Hepatomegaly.
Splenomegaly.
Anuria.
Ecchymosis.
The Correct Answer is D
Choice A reason: Hepatomegaly, or enlarged liver, is not a typical finding in DIC. While DIC can affect multiple organs due to widespread microvascular thrombosis and bleeding, hepatomegaly is more commonly associated with other conditions such as liver diseases or congestive heart failure.
Choice B reason: Splenomegaly, or enlarged spleen, is also not a common finding in DIC. Although the spleen can be involved in various hematologic disorders, DIC primarily affects the coagulation and fibrinolytic systems, leading to bleeding and clotting issues rather than spleen enlargement.
Choice C reason: Anuria, or absence of urine production, can occur in severe cases of DIC due to acute kidney injury from microvascular thrombosis or bleeding. However, it is not as common a finding as petechiae, bleeding gums, and ecchymosis. Anuria indicates a critical state requiring immediate intervention but is not the primary expected finding in DIC.
Choice D reason: Ecchymosis, or bruising, is a common finding in DIC. DIC involves widespread activation of the coagulation cascade leading to the consumption of clotting factors and platelets, resulting in bleeding manifestations such as petechiae, bleeding gums, and ecchymosis. These signs indicate the body's inability to form stable clots and the presence of spontaneous bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring amylase and lipase levels is the best way to determine the effectiveness of treatment in a patient with pancreatitis. These enzymes are produced by the pancreas, and their levels in the blood increase significantly during an episode of pancreatitis. As treatment progresses and the inflammation of the pancreas decreases, the levels of these enzymes should return to normal. Therefore, checking the levels of amylase and lipase is a direct indicator of the patient's response to treatment.
Choice B reason: Hematocrit and hemoglobin levels are important for assessing overall blood volume and oxygen-carrying capacity, but they are not specific indicators of pancreatitis treatment effectiveness. While these levels can provide information about the patient's general health and hydration status, they do not specifically reflect changes in pancreatic inflammation.
Choice C reason: Red blood cell count is another measure of the blood's oxygen-carrying capacity and overall health, but like hematocrit and hemoglobin, it is not specific to pancreatitis. Changes in red blood cell count can occur due to various factors, but they do not provide direct information about the effectiveness of pancreatitis treatment.
Choice D reason: Serum uric acid levels are typically monitored in conditions such as gout or kidney stones, and they are not related to pancreatitis. Monitoring serum uric acid would not provide useful information about the patient's response to pancreatitis treatment.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Auscultating for irregular heart tones can provide useful information about the heart’s rhythm and potential arrhythmias. However, it is not the most specific or definitive assessment for diagnosing a myocardial infarction (MI).
Choice B reason: Assessing for ST elevations on continuous telemetry and 12-lead EKG is critical in diagnosing a myocardial infarction. ST-segment elevation is a key indicator of an acute MI, specifically indicating myocardial injury. Continuous telemetry and 12-lead EKG provide real-time and detailed views of the heart's electrical activity, helping to identify ischemic changes.
Choice C reason: Assessing for elevated Troponin levels is essential because Troponins are cardiac biomarkers that increase significantly when there is damage to the heart muscle, such as during an MI. Elevated Troponin levels are highly specific and sensitive indicators of myocardial infarction, making this assessment crucial.
Choice D reason: Assessing for low magnesium levels is not directly related to diagnosing a myocardial infarction. While magnesium levels are important for overall cardiac function, they do not specifically indicate an acute MI.
Choice E reason: Assessing the client's blood pressure is an important part of a comprehensive assessment and can provide information about the patient's hemodynamic status. However, it is not specific to diagnosing a myocardial infarction.
Choice F reason: Assessing if the pain radiates to the left arm is an important symptom of a myocardial infarction. However, while it supports the suspicion of an MI, it is not as definitive as ST elevation on an EKG or elevated Troponin levels.
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