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 C

Explanation

Reasoning:

Choice A reason: Addison disease results from adrenal insufficiency, causing deficient cortisol and aldosterone production. This leads to symptoms like hypotension, hyponatremia, and hyperkalemia, opposite to the cortisol excess seen in Cushing syndrome, which involves weight gain, hypertension, and hyperglycemia due to elevated adrenal cortex activity.

Choice B reason: Hashimoto disease is an autoimmune thyroiditis causing hypothyroidism, with low thyroid hormone levels leading to fatigue, weight gain, and cold intolerance. It does not involve adrenal cortex cortisol excess, unlike Cushing syndrome, which is characterized by hypercortisolism and distinct metabolic and physical symptoms.

Choice C reason: Cushing syndrome is defined by excess free circulating cortisol from the adrenal cortex, due to pituitary tumors, adrenal hyperplasia, or exogenous steroids. This causes weight gain, moon face, hypertension, and hyperglycemia, reflecting cortisol’s effects on metabolism, fat distribution, and fluid balance, making it the correct disorder.

Choice D reason: Graves disease is an autoimmune condition causing hyperthyroidism, with excess thyroid hormone leading to weight loss, tachycardia, and heat intolerance. It does not involve adrenal cortex cortisol production, unlike Cushing syndrome, which is specifically related to hypercortisolism and its systemic metabolic effects.

A. Offer liquids frequently, in large quantities B. Allow optimum physical activity before meals to expedite digestion C. Help the client sit upright when eating and feed slowly D. Instruct the client to lie on the bed when eating

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Offering large quantities of liquids frequently increases aspiration risk in clients with dysphagia from neurological disorders. Large volumes can overwhelm swallowing mechanisms, leading to choking or pneumonia. Controlled, small sips with proper positioning are safer to ensure nutrition without compromising airway safety.

Choice B reason: Allowing physical activity before meals may improve appetite but does not address swallowing difficulties. Activity does not facilitate safe swallowing in neurological disorders, where muscle coordination is impaired. Proper positioning and pacing during feeding are more effective to prevent aspiration and ensure nutritional intake.

Choice C reason: Helping the client sit upright and feeding slowly minimizes aspiration risk in neurological dysphagia. Upright positioning aligns the airway to prevent food or liquid entry, and slow feeding allows better coordination of swallowing muscles, reducing choking and ensuring adequate nutrition, critical for safe intake.

Choice D reason: Instructing the client to lie down while eating is dangerous in dysphagia, as it increases aspiration risk. Lying down allows food or liquids to enter the airway, potentially causing pneumonia. Upright positioning is essential to facilitate safe swallowing and prevent complications in neurological disorders.

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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

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Correct Answer is C

Explanation

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

Correct Answer is C

Explanation

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The client with this condition is most at risk for which of the following?

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A client has been placed on corticosteroid therapy for Addison's disease. The nurse should be aware of which of the following side effects associated with this type of therapy? (Select all that apply)

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A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor?

A client who is in the third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the client’s iron stores?

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?