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 A

Explanation

Reasoning:

Choice A reason: A sodium level of 150 mEq/L indicates hypernatremia, which occurs in diabetes insipidus when fluid restriction exacerbates water loss from polyuria. Without adequate ADH, the kidneys cannot conserve water, and restricting fluids further increases serum sodium concentration, reflecting dehydration and supporting the suspicion of fluid restriction.

Choice B reason: A phosphate level of 4.0 mg/dL is within the normal range and unrelated to fluid restriction in diabetes insipidus. Phosphate levels are affected by bone metabolism or renal function, not directly by ADH deficiency or fluid intake, making this finding irrelevant to the client’s fluid management strategy.

Choice C reason: A blood glucose level of 60 mg/dL is at the lower end of normal but unrelated to fluid restriction in diabetes insipidus. Glucose levels are affected by metabolic conditions like diabetes mellitus, not water balance issues caused by ADH deficiency, so this does not indicate fluid restriction.

Choice D reason: A potassium level of 2.9 mmol/L indicates hypokalemia, which is not directly linked to fluid restriction in diabetes insipidus. Potassium imbalances may result from other causes, like diuretic use or gastrointestinal losses, but they do not reflect the dehydration or sodium concentration changes associated with restricted fluid intake.

A. Hemoglobin A B. Hemoglobin S C. Hemoglobin M D. Hemoglobin F

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Hemoglobin A is the normal adult hemoglobin, comprising two alpha and two beta chains. In sickle cell anemia, a mutation in the beta-globin gene produces hemoglobin S, not hemoglobin A, which does not cause sickling or the vaso-occlusive crises characteristic of the disease.

Choice B reason: Hemoglobin S is the abnormal hemoglobin in sickle cell anemia, resulting from a point mutation in the beta-globin gene. This causes red blood cells to sickle under stress, leading to hemolysis and vaso-occlusion, resulting in pain, organ damage, and the clinical features of sickle cell crises.

Choice C reason: Hemoglobin M is a rare hemoglobin variant causing methemoglobinemia, not sickle cell anemia. It results from mutations affecting heme iron, leading to cyanosis, not the sickling and vaso-occlusion seen with hemoglobin S, making it irrelevant to the client’s condition.

Choice D reason: Hemoglobin F, or fetal hemoglobin, is present in newborns and persists in small amounts in adults. In sickle cell anemia, increased hemoglobin F can reduce sickling, but it is not the cause. Hemoglobin S drives the disease’s pathophysiology, not hemoglobin F.

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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

A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?

Correct Answer is A

Explanation

A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia?

Correct Answer is B

Explanation

A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?

The health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?

A nurse is providing care to a client diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse understands that the primary problem involves which gland?

The nurse is assessing a client who is a strict vegetarian. What type of anemia is the nurse aware that this client is at risk for?

For a client with Hodgkin disease who has developed neutropenia, what is an appropriate nursing intervention to include in the care plan?

A nurse is assessing a client admitted with SIADH. What finding would the nurse expect to assess in a client with SIADH?

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client’s home environment, the nurse should focus on which nursing diagnosis?