A nurse is assessing the vital signs for a 10-year old child following a burn injury. Which of the following clinical manifestations indicate early septic shock?
Urinary output 100 mL/hr
Temperature 39.1C (102.4° F)
Blood pressure 130/90 mm Hg
Heart ráte 60/min
The Correct Answer is B
A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.
B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.
C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.
D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asking the client to look away may reduce anxiety for some, but it does not minimize discomfort or promote understanding.
B. Using a larger needle would likely increase discomfort and is not consistent with atraumatic care, which aims to minimize pain.
C. Administering the injection quickly might reduce discomfort but does not address the child’s emotional needs or ensure proper understanding of the procedure.
D. Explaining the procedure in simple terms helps the child understand what will happen, reducing fear and promoting cooperation. This is an important aspect of atraumatic care.
Correct Answer is D
Explanation
A. A low-fiber diet is not appropriate for Hirschsprung disease, as it can worsen constipation and other symptoms.
B. Daily enemas are typically used for symptom management, but they do not address the underlying cause of the disease.
C. While a colostomy may be performed in some cases, it is usually not permanent. Surgical removal of the aganglionic portion of the colon is the primary treatment.
D. The definitive treatment for Hirschsprung disease is the surgical removal of the aganglionic portion of the colon to allow normal bowel function.
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