A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?
Sepsis.
Hypovolemic shock.
Myocardial infarction.
Pulmonary embolism.
The Correct Answer is A
Choice A rationale
Sepsis is a systemic inflammatory response to infection, often characterized by fever (temperature of 38°C or higher) and tachycardia (heart rate of 120 beats per minute or higher). These symptoms indicate the body’s response to a severe infection.
Choice B rationale
Hypovolemic shock is caused by significant fluid loss, leading to decreased blood volume and perfusion. It typically presents with hypotension and tachycardia, but not necessarily fever.
Choice C rationale
Myocardial infarction (heart attack) is characterized by chest pain, shortness of breath, and other symptoms, but fever and tachycardia are not primary indicators.
Choice D rationale
Pulmonary embolism involves a blockage in the pulmonary arteries, leading to symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, but not typically fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Acute pancreatitis is characterized by severe epigastric pain and elevated levels of amylase and lipase. These enzymes are released into the bloodstream when the pancreas is inflamed, making acute pancreatitis the most likely diagnosis.
Choice B rationale
Acute hematochezia refers to the passage of fresh blood through the anus, usually in or with stools. It is not associated with elevated amylase and lipase levels or severe epigastric pain.
Choice C rationale
Left heart failure can cause symptoms such as shortness of breath and fluid retention, but it does not typically cause elevated amylase and lipase levels or severe epigastric pain.
Choice D rationale
Chronic hepatic failure involves long-term liver damage and may present with jaundice, ascites, and other symptoms. It is not associated with elevated amylase and lipase levels or severe epigastric pain.
Correct Answer is B
Explanation
Choice A rationale
Checking blood sugar levels before each meal is a good practice for managing diabetes and does not indicate a need for further teaching.
Choice B rationale
Skipping medication if blood sugar is normal indicates a misunderstanding of diabetes management. Medications should be taken as prescribed to maintain consistent blood sugar levels.
Choice C rationale
Following a balanced diet and exercising regularly are important components of diabetes management and do not indicate a need for further teaching.
Choice D rationale
Monitoring feet for cuts or sores is crucial for diabetes management to prevent complications like infections and ulcers.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.