A nurse is teaching a client who has stage IV pancreatic cancer about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
"DIC is controllable with lifelong heparin usage.”.
"DIC is caused by abnormal coagulation involving fibrinogen.”.
"DIC is a genetic disorder involving a vitamin K deficiency.”.
"DIC is characterized by an elevated platelet count.”.
The Correct Answer is B
Choice A rationale
DIC is not controllable with lifelong heparin usage. Heparin may be used to manage DIC, but it is not a permanent solution, and the underlying cause of DIC must be addressed.
Choice B rationale
DIC is caused by abnormal coagulation involving fibrinogen. It is characterized by widespread activation of the clotting cascade, leading to both clot formation and bleeding due to consumption of clotting factors and platelets.
Choice C rationale
DIC is not a genetic disorder involving a vitamin K deficiency. It is an acquired condition resulting from severe illnesses or injuries that trigger abnormal clotting and bleeding processes.
Choice D rationale
DIC is not characterized by an elevated platelet count. Instead, it involves thrombocytopenia due to the consumption of platelets in widespread clotting, leading to a decreased platelet count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Providing 1,000 mL of water every 12 hours is not directly related to preventing infection or other complications post-transplant.
Choice B rationale
Keeping blood pressure equipment in the client's room helps prevent cross-contamination and infection by not sharing equipment with other clients.
Choice C rationale
A negative airflow room is used for clients with airborne infections, not for those undergoing a stem cell transplant.
Choice D rationale
Monitoring vital signs every 8 hours is insufficient; more frequent monitoring is needed post-transplant to detect complications early.
Correct Answer is []
Explanation
Rationale for correct condition: Mucositis is a common side effect of chemotherapy that causes inflammation and soreness in the mouth. The client reports mouth soreness and dry mucous membranes, consistent with mucositis. The presence of mild erythema on the oral mucosa also supports this diagnosis. Chemotherapy drugs such as vincristine and anthracycline are known to cause mucositis. Addressing mucositis early is crucial for maintaining the client’s nutrition and hydration.
Rationale for actions: Providing a soft sponge toothbrush helps maintain oral hygiene without causing further irritation. Maintaining the client’s diet ensures adequate nutrition, which is essential for healing mucositis. Pad the siderails of the bed is unnecessary in this scenario, as there's no indication of seizure risk. Requesting an antiemetic is irrelevant since the client has no significant nausea or vomiting.
Rationale for parameters: Monitoring weight loss helps assess the client’s nutritional status and the effectiveness of dietary interventions. Tracking intake and output ensures the client is adequately hydrated and that oral intake is sufficient. Edema monitoring is unnecessary, as there's no sign of fluid retention. Steatorrhea is not relevant in this context, as there's no indication of fat malabsorption.
Rationale for incorrect conditions: Diarrhea is not indicated as the client’s primary complaint is mouth soreness, not gastrointestinal upset. Angioedema is characterized by swelling and is not observed in the client. Seizures are not relevant here, as the client shows no neurological signs suggestive of seizure activity.
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