Burns Pediatric Primary Care 7th Edition Test Bank Related

Review Burns Pediatric Primary Care 7th Edition Test Bank related questions and content

An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?

  • A. Risk for increased cardiac output related to fluid volume excess
  • B. Disturbed sensory perception related to bleeding into tissues
  • C. Alteration in tissue perfusion related to bleeding and diminished blood flow
  • D. Risk for aspiration related to constriction of the respiratory musculature
Correct Answer: C

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.