A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Activation of complement pathways.

Inhibition of red blood production.

Production of extra platelets.

Depletion of clotting factors.

Answer and Explanation

The Correct Answer is D

Rationale

A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.

B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.

C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.

D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.

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Correct Answer is D

Explanation

A. This information is crucial as it provides insight into the client's abdominal assessment post- laparotomy. A soft abdomen with absent bowel sounds suggests normal bowel function has not yet returned, which is common after abdominal surgery. However, this does not have immediate postoperative implications.

B. A history of vomiting prior to surgery could indicate a gastrointestinal issue that may impact the client’s recovery or increase the risk of complications such as nausea and vomiting postoperatively.However, this history may not immediately affect the current postoperative care as much as some other findings (such as changes in bowel sounds or bleeding) in the acute postoperative period.

C. This information provides reassurance regarding circulation and mobility of the lower extremities. However, it may not be as urgent to report immediately unless there were concerns during surgery or potential complications related to positioning or circulation.

D.This should be reported to ensure that the client is receiving proper hydration and that their hydration status is carefully monitored. It’s especially important to monitor for dehydration or difficulties with oral intake following surgery.

A. Obtain thickening powder before providing any more fluids. B. Assist the spouse and carefully give the client small sips of water. C. Ask the spouse to stop and assess the client's swallowing reflex. D. Give the spouse a straw to help facilitate the client's drinking.

Correct Answer is C

Explanation

Rationale

A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.

B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

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A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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