A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) (IB IIIA. inhibitor. Which assessment finding places the client at greatest risk?
Unresponsive to painful stimuli.
Presence of hematemesis.
Incontinent with blood in urine.
Blood pressure of 100/60 mm Hg.
The Correct Answer is B
A. Unresponsiveness to painful stimuli indicates a potential neurological issue but does not directly correlate with the risk of bleeding associated with eptifibatide use.
B. Hematemesis indicates gastrointestinal bleeding, which is a significant concern in patients on eptifibatide, as it increases the risk of serious bleeding complications.
C. Blood in urine (hematuria) can indicate a urinary tract issue or bleeding but is less critical than gastrointestinal bleeding in this context.
D. A blood pressure of 100/60 mm Hg may indicate some degree of hypotension but is not as urgent as identifying active bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Depletion of clotting factors occurs in DIC as the coagulation cascade is activated, leading to the formation of clots and subsequent consumption of clotting factors, which can result in bleeding.
B. Activation of complement pathways is part of the immune response but does not directly explain the coagulopathy seen in DIC.
C. Production of extra platelets may occur, but in DIC, platelets are consumed more rapidly than they can be produced, contributing to bleeding risks.
D. Inhibition of red blood production is not directly related to the coagulation issues seen in DIC; rather, it relates more to the overall effects of shock and organ dysfunction.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Acute stress disorder (ASD) is characterized by symptoms such as intrusive memories, nightmares, and negative mood changes following a traumatic event, which aligns with the client's experiences of having horrible thoughts and memories about her house collapsing.
Traumatic stress exposure refers to the distressing experience she endured during the hurricane when her house collapsed, leading to her current emotional state.
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