While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
Platelet count, blood glucose levels, and white blood cell (WBC) count
Thrombin time, calcium levels, and potassium levels
Platelet count, prothrombin time, and partial thromboplastin time
Fibrinogen level, WBC, and platelet count
The Correct Answer is C
Reasoning:
Choice A reason: Platelet count and WBC count are relevant, but blood glucose levels are not specific to DIC. DIC involves widespread clotting and bleeding, depleting platelets and coagulation factors, affecting clotting times. Glucose levels are unrelated to the coagulopathy central to DIC’s pathophysiology, making this set less comprehensive.
Choice B reason: Thrombin time is relevant to DIC, but calcium and potassium levels are not primary indicators. Calcium may affect clotting in specific contexts, but DIC primarily involves consumption of platelets and clotting factors, prolonging prothrombin and partial thromboplastin times, making these more critical parameters.
Choice C reason: Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT) are key in DIC monitoring. DIC causes widespread microthrombi, consuming platelets and clotting factors, leading to low platelets and prolonged PT/PTT. These parameters directly reflect the coagulopathy and bleeding risk, making them essential for diagnosis and management.
Choice D reason: Fibrinogen level and platelet count are important in DIC, as both are consumed in widespread clotting. However, WBC count is less specific, as it reflects infection or inflammation, not coagulopathy. PT and PTT better capture the clotting factor depletion central to DIC’s pathophysiology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
Choice A reason: Bradycardia, or slow heart rate, is not typically associated with diabetes insipidus. The condition causes dehydration due to excessive water loss, leading to hypovolemia, which typically increases heart rate (tachycardia) to compensate for reduced blood volume, not slowing it, making bradycardia an unlikely sign.
Choice B reason: Oliguria, or low urine output, is not a feature of diabetes insipidus. The condition results from ADH deficiency, causing the kidneys to produce large volumes of dilute urine (polyuria). Oliguria is more common in conditions like acute kidney injury or dehydration from other causes.
Choice C reason: Hypotension is a clinical sign of diabetes insipidus due to significant water loss from polyuria, leading to hypovolemia. Reduced blood volume decreases blood pressure, as the cardiovascular system struggles to maintain adequate perfusion, making hypotension a common finding in severe or untreated cases.
Choice D reason: Hypertension is not typically associated with diabetes insipidus. The condition leads to dehydration and hypovolemia, which lower blood pressure. Hypertension might occur in conditions like SIADH, where water retention increases blood volume, but this is opposite to the pathophysiology of diabetes insipidus.
Correct Answer is B
Explanation
Reasoning:
Choice A reason: Palpating lymph nodes and tonsils is relevant for assessing infections or malignancies but is not a primary intervention for thrombocytopenia. Corticosteroids treat thrombocytopenia by suppressing autoimmune platelet destruction, and the focus is on bleeding prevention, not lymphoid assessment, which is secondary to managing low platelet counts.
Choice B reason: Eliminating aspirin and NSAIDs is critical in thrombocytopenia, as these drugs inhibit platelet function, increasing bleeding risk in patients with low platelet counts. Corticosteroids improve platelet production, but concurrent use of antiplatelet drugs could exacerbate bleeding tendencies, making their elimination a primary nursing intervention.
Choice C reason: Gradually tapering corticosteroids is important to prevent adrenal suppression but is not the primary intervention during initial therapy for thrombocytopenia. The immediate focus is on preventing bleeding complications due to low platelets, with tapering being a later consideration once platelet counts stabilize.
Choice D reason: Examining extremities for redness may detect infection or inflammation but is not the primary intervention for thrombocytopenia. Bleeding risk from low platelets is the main concern, and while redness could indicate complications, eliminating drugs that impair platelet function is more critical to prevent hemorrhage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
