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. The patient should increase intake of fluids. Increased fluid intake helps flush excess calcium from the kidneys, which is vital for patients with hypercalcemia, a common complication of multiple myeloma.
B. The patient should increase intake of fresh fruits. Fresh fruits can be healthy but do not directly reduce hypercalcemia risk. Fluid intake is more critical in preventing calcium build up.
C. The patient should decrease intake of red meat. While reducing red meat can be beneficial for overall health, it does not directly address hypercalcemia.
D. The patient should avoid alcoholic beverages. Avoiding alcohol is generally beneficial, but it is not specifically related to managing hypercalcemia in multiple myeloma.
Correct Answer is A
Explanation
A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.
B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.
C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.
D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.