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 B
Explanation
A. Carrying a water bottle is appropriate as hydration is important, especially for those with spinal cord injuries who may have a higher risk of urinary tract infections.
B. For an adolescent with spina bifida, bladder function is often impaired, and intermittent catheterization is usually required 4-6 times a day to prevent urinary retention and infections. Twice a day may be insufficient.
C. Using a suppository for bowel management is a common and recommended practice for individuals with spina bifida.
D. Doing wheelchair exercises is an appropriate way to maintain muscle strength and prevent complications related to immobility.
Correct Answer is D
Explanation
A. Tracheoesophageal fistula involves an abnormal connection between the esophagus and trachea, typically presenting with respiratory distress, coughing, and feeding difficulties, not a palpable abdominal mass and blood in stools.
B. Hypertrophic pyloric stenosis is characterized by projectile vomiting, dehydration, and an olive-shaped mass in the upper abdomen, not blood and mucus in the stools.
C. Inguinal hernia may present with a bulging mass in the groin area, but it does not cause blood or mucus in stools.
D. Intussusception is characterized by the telescoping of one part of the intestine into another, which can cause a palpable mass, abdominal pain, and stools mixed with blood and mucus (often referred to as "currant jelly" stools).
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