A nurse is assisting with the care of a preschooler who sustained a major burn injury 5 days ago. Which of the following findings should the nurse identify as a manifestation of sepsis?
Polyuria
Disorientation
Hyperactive bowel sounds
Hypoglycemia
The Correct Answer is B
A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rolling from back to side typically occurs around 4 to 5 months of age.
B. At 3 months, an infant is expected to be able to hold a rattle.
C. Holding arms out to be picked up usually develops around 7 to 9 months of age.
D. Fear toward strangers, known as stranger anxiety, typically begins around 6 to 8 months of age.
Correct Answer is A
Explanation
A. Ensuring the child’s arm doesn’t hang down for extended periods can help prevent swelling and discomfort.
B. Submerging a fiberglass cast can damage the material and is not recommended.
C. It is important to encourage the child to move their fingers to maintain circulation and prevent stiffness.
D. Using a pencil to scratch inside the cast can cause injury or damage to the skin and should be avoided.
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