The nurse is reviewing plans of care for several clients. The nurse recognizes which client is most at risk for developing disseminated intravascular coagulation (DIC)?

A client admitted with suspected cocaine overdose

A client admitted with sepsis

A client with heart failure and renal failure

A client with a stage IV pressure injury

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: A cocaine overdose can cause cardiovascular complications like hypertension or infarction, but it is not a primary trigger for DIC. While cocaine may induce inflammation or vascular damage, it lacks the systemic activation of coagulation pathways seen in conditions like sepsis, making it a less likely cause of DIC in this context.

Choice B reason: Sepsis is a leading cause of DIC due to systemic infection triggering widespread activation of the coagulation cascade. Endotoxins or cytokines promote microthrombi formation, consuming platelets and clotting factors, leading to bleeding tendencies. Sepsis-induced inflammation and endothelial damage make this client the most at risk for developing DIC.

Choice C reason: Heart failure and renal failure may cause fluid imbalances and inflammation but are not primary triggers for DIC. These conditions can contribute to coagulopathy indirectly, but they lack the intense systemic inflammatory response and endothelial injury seen in sepsis, making them less likely to cause DIC.

Choice D reason: A stage IV pressure injury may lead to localized infection or inflammation, but it is not a primary driver of DIC. While severe infections could contribute, the systemic activation of coagulation seen in DIC is more commonly triggered by conditions like sepsis, making this client less at risk.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Continuous oxygen therapy is not a standard preventive measure for sickle cell crises. Oxygen is used during acute crises to treat hypoxia from vaso-occlusion, but daily hydration is more effective for prevention, as it reduces blood viscosity and sickling, making this inappropriate.

Choice B reason: Avoiding all sports is overly restrictive for sickle cell anemia. Moderate exercise can be safe with proper hydration and rest. Complete avoidance does not directly prevent crises and may reduce quality of life, whereas hydration directly addresses the risk of sickling and vaso-occlusion.

Choice C reason: Avoiding activities causing shortness of breath is partially correct, as overexertion can trigger hypoxia and crises. However, it is less specific than hydration, which directly reduces blood viscosity and sickling, preventing crises more effectively across various situations, not just during exertion.

Choice D reason: Drinking at least 8 glasses of water daily is critical in sickle cell anemia to prevent crises. Adequate hydration reduces blood viscosity, preventing red blood cell sickling and vaso-occlusion. Dehydration increases sickling risk, making consistent fluid intake a key preventive strategy for this client.

A. Explain that the client’s physical changes are a result of excessive corticosteroids B. Offer clothing or bedding that’s cool and comfortable C. Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather D. Suggest a high-carbohydrate, low-protein diet

Correct Answer is A

Explanation

Reasoning:

Choice A reason: Explaining that physical changes in Cushing’s syndrome, like moon face and weight gain, result from excessive corticosteroids helps the client understand their condition. Cortisol excess causes fat redistribution and metabolic changes, and education promotes adherence to treatment and coping with body image changes, improving psychological and physical management.

Choice B reason: Offering cool, comfortable clothing or bedding addresses symptoms like heat intolerance in Cushing’s syndrome due to cortisol’s metabolic effects. However, it is less critical than education about the condition, as it does not address the underlying cause or promote understanding and adherence to long-term management strategies.

Choice C reason: Increasing salt and fluid intake is appropriate for Addison’s disease, not Cushing’s syndrome, where cortisol’s mineralocorticoid effects cause fluid retention and hypertension. This intervention could worsen fluid overload and hyponatremia, making it inappropriate and potentially harmful for managing Cushing’s syndrome symptoms.

Choice D reason: A high-carbohydrate, low-protein diet is not recommended for Cushing’s syndrome. Cortisol excess causes protein catabolism and hyperglycemia, so a balanced diet with adequate protein supports muscle maintenance and glucose control. This dietary suggestion does not address the metabolic needs of the condition.

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The nurse is reviewing plans of care for several clients. The nurse recognizes which client is most at risk for developing disseminated intravascular coagulation (DIC)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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