Which of the following is a key teaching point when educating a client about disseminated intravascular coagulation (DIC)?
Consuming a diet high in vitamin K to promote clotting
Stopping all medications to prevent interactions with clotting factors
Engaging in physical activity to promote blood flo
Avoiding activities that may cause injury or bleeding
The Correct Answer is D
Choice A Reason:
Consuming a diet high in vitamin K to promote clotting is not typically recommended for patients with DIC. While vitamin K is essential for clotting, DIC involves both excessive clotting and bleeding. Increasing vitamin K intake could exacerbate clotting issues without addressing the underlying imbalance.
Choice B Reason:
Stopping all medications to prevent interactions with clotting factors is not advisable. Patients with DIC often require medications to manage their condition, including anticoagulants and treatments for the underlying cause. Discontinuing all medications could lead to uncontrolled symptoms and complications.
Choice C Reason:
Engaging in physical activity to promote blood flow is generally beneficial for overall health, but in the context of DIC, it must be approached with caution. Physical activity can increase the risk of injury and bleeding, which is a significant concern for patients with DIC. Therefore, any exercise regimen should be carefully monitored and tailored to the patient's condition.
Choice D Reason:
Avoiding activities that may cause injury or bleeding is crucial for patients with DIC. Due to the risk of spontaneous bleeding and the potential for minor injuries to lead to significant blood loss, patients must take precautions to minimize these risks. This includes avoiding contact sports, using soft-bristled toothbrushes, and being cautious with sharp objects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Narrowing pulse pressure is not typically associated with contusions from a motor-vehicle crash. It is more commonly seen in conditions like cardiac tamponade or severe blood loss. While it can indicate a serious condition, it is not a direct result of a contusion.
Choice B Reason:
Drainage of clear fluid from the ears, known as otorrhea, can indicate a basilar skull fracture rather than a simple contusion. This finding suggests cerebrospinal fluid leakage, which is a serious complication requiring immediate medical attention.
Choice C Reason:
Periods of unconsciousness and/or confusion are expected findings in clients with contusions, especially if the brain is involved. These symptoms indicate a concussion or more severe brain injury, which can result from the impact of a motor-vehicle crash.
Choice D Reason:
Extensive bruising in the mastoid area, known as Battle's sign, is indicative of a basilar skull fracture rather than a contusion. This type of bruising appears behind the ear and is a sign of a more severe head injury.
Correct Answer is C
Explanation
Choice A Reason:
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typically 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.
Choice B Reason:
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.
Choice C Reason:
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.
Choice D Reason:
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.
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