A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Progressive increase in platelet production.
Excessive thrombosis and bleeding.
Immediate sodium and fluid retention.
Increased clotting factors.
The Correct Answer is B
A. Progressive increase in platelet production: In DIC, platelets are rapidly consumed, not increased, due to widespread clotting in the blood vessels.
B. Excessive thrombosis and bleeding: DIC is a complex condition where there is widespread activation of the clotting cascade, leading to excessive clotting and subsequent depletion of platelets and clotting factors, resulting in both thrombosis and bleeding.
C. Immediate sodium and fluid retention: Sodium and fluid retention are not specific findings in DIC; they may occur in cases of renal or heart failure but are unrelated to the clotting issues in DIC.
D. Increased clotting factors: In DIC, clotting factors are depleted as they are used up in widespread clotting, leading to bleeding when factors are exhausted.
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Correct Answer is A
Explanation
A. Results indicate the presence of Reed Sternberg cells: Reed-Sternberg cells are a defining characteristic of Hodgkin disease, a type of lymphoma. Their presence in biopsy samples confirms the diagnosis, distinguishing Hodgkin disease from other types of lymphomas and leukemias.
B. The patient is cyanotic: Cyanosis, or bluish skin discoloration due to low oxygen levels, is not a common sign of Hodgkin disease. It may occur in advanced disease due to respiratory compromise but is not a defining characteristic.
C. The patient is complaining of excessive thirst and hunger: Excessive thirst and hunger are more characteristic of diabetes mellitus, not Hodgkin disease. These symptoms are unrelated to the lymphatic involvement seen in Hodgkin disease.
D. Results indicate the presence of the Philadelphia chromosome: The Philadelphia chromosome is a genetic abnormality associated with chronic myelogenous leukemia (CML), not Hodgkin disease. Its presence suggests a different hematologic malignancy.
Correct Answer is C
Explanation
A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.
B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.
C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.
D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.