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?

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.

Correct Answer: A

Rationale: The primary purpose of performing breast self-examination is to detect any abnormal changes in the breast tissue, including the presence of cancerous lumps. By regularly examining their breasts, women can become familiar with the normal look and feel of their breasts, making it easier to identify any new lumps or other changes that may indicate a potential problem, such as breast cancer. Detecting cancerous lumps early through self-examination can lead to early detection and improved treatment outcomes. It is important for women to perform breast self-examinations regularly and report any concerning findings to their healthcare provider for further evaluation.

Correct Answer: C

Rationale: Thiotepa is a cell cycle-nonspecific alkylating agent that exerts its therapeutic effects by interfering with both DNA replication and RNA transcription. The alkylating properties of thiotepa lead to the cross-linking of DNA strands, ultimately inhibiting DNA replication. Additionally, thiotepa can also disrupt RNA synthesis, further affecting protein production and cell function. This combined action on DNA replication and RNA transcription contributes to the cytotoxic effects of thiotepa on rapidly dividing cancer cells.

Correct Answer: B

Rationale: Lung cancer causes the most deaths in women. Despite breast cancer being the most common type of cancer in women, lung cancer is responsible for the highest number of deaths among women due to factors such as smoking, secondhand smoke exposure, and other environmental factors. It is crucial for women to be aware of the risks associated with lung cancer, even if they are non-smokers, and to take steps to reduce their risk factors through lifestyle changes and early detection methods.

Correct Answer: D

Rationale: Class V findings on a Pap test indicate the presence of severely abnormal cells, suggesting a high likelihood of precancerous or cancerous changes. Therefore, it calls for a biopsy as soon as possible to further investigate and determine the appropriate course of action. Immediate follow-up and intervention are crucial in cases of Class V Pap test results to address any potential serious health concerns.