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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Systolic blood pressure above 70 mm Hg is a goal in hypovolemia but is not the most specific outcome for DIC-related bleeding. While low blood pressure reflects fluid loss, addressing bleeding directly prevents further volume depletion, making reduced bleeding a more targeted and measurable outcome.
Choice B reason: A stable level of consciousness is important but not directly tied to deficient fluid volume from bleeding in DIC. Altered consciousness may result from cerebral ischemia or hyponatremia, but reducing bleeding is the primary goal to stabilize fluid volume and prevent further hemodynamic compromise.
Choice C reason: Urine output of 30 mL/hour or more indicates adequate renal perfusion but is a secondary outcome in DIC-related bleeding. While it reflects fluid status, directly addressing bleeding through interventions like transfusions or clotting factor replacement is more specific to correcting the underlying fluid volume deficit.
Choice D reason: Decreased bleeding is the most appropriate outcome for deficient fluid volume in DIC, as bleeding from mucosal and venipuncture sites directly causes volume loss. Reducing hemorrhage through platelet or factor replacement stabilizes fluid volume, preventing hypovolemia and its complications, making this the most measurable and relevant outcome.
Correct Answer is C
Explanation
Reasoning:
Choice A reason: Initiating thrombolytic therapy within 12 hours is too late for optimal ischemic stroke outcomes. Beyond 4.5 hours, the risk of hemorrhage outweighs benefits, as ischemic tissue becomes necrotic, reducing the effectiveness of thrombolytics like tPA in restoring blood flow and improving function.
Choice B reason: A 9-hour window for thrombolytic therapy exceeds the recommended time frame for ischemic stroke. After 4.5 hours, the risk of hemorrhagic transformation increases, and neuronal salvage is less likely due to prolonged ischemia, making this time frame ineffective for achieving optimal functional recovery.
Choice C reason: Thrombolytic therapy within 3 hours of ischemic stroke onset maximizes functional outcomes. Tissue plasminogen activator (tPA) dissolves clots, restoring blood flow to viable brain tissue. Early administration minimizes neuronal damage, reduces disability, and improves recovery, with guidelines supporting a 3–4.5-hour window for eligible patients.
Choice D reason: A 6-hour window for thrombolytics is beyond the optimal 3–4.5-hour period for ischemic stroke. While some patients may benefit up to 4.5 hours, delays increase hemorrhage risk and reduce the likelihood of salvaging ischemic tissue, leading to poorer functional outcomes compared to earlier intervention.
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