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 A
Explanation
A. Administering bronchodilator therapy immediately before chest physiotherapy helps open the airways, making the therapy more effective.
B. Administering the bronchodilator 2 hours before is too early to have the desired effect during physiotherapy.
C. Administering the bronchodilator 2 hours after does not support the immediate effectiveness of chest physiotherapy.
D. Administering the bronchodilator immediately after chest physiotherapy does not provide the benefit needed during the procedure.
Correct Answer is B
Explanation
A. Alanine aminotransferase (ALT) is a liver enzyme and not typically relevant for diagnosing juvenile idiopathic arthritis.
B. Erythrocyte sedimentation rate (ESR) is a marker of inflammation and is commonly used in the evaluation and monitoring of juvenile idiopathic arthritis.
C. Potassium levels are not directly related to juvenile idiopathic arthritis and its diagnosis.
D. BUN (blood urea nitrogen) is a measure of kidney function and is not specific to juvenile idiopathic arthritis.
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