A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)
A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min.
A client who has a heart rate of 132/min and a respiratory rate of 30/min.
A client who has a decrease in level of consciousness and a heart rate greater than 130/min.
A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³).
A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.
Correct Answer : B,C
Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.
Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.
Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.
Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.
Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Gingivitis, an inflammation of the gums, is not specifically associated with a decreased CD4+ T-cell count. While individuals with HIV/AIDS may have an increased risk for periodontal diseases due to a compromised immune system, gingivitis is not directly linked to the CD4+ T-cell count¹.
Choice B reason:
Xerostomia, or dry mouth, can be a side effect of medications or secondary to other conditions but is not an infectious condition. It is not directly related to a decreased CD4+ T-cell count, although it may be more common in individuals with HIV/AIDS due to various factors, including medication side effects¹.
Choice C reason:
Candidiasis, also known as oral thrush, is a common opportunistic infection in individuals with HIV/AIDS, especially when the CD4+ T-cell count is significantly decreased. It is caused by the fungus Candida and can lead to white patches in the mouth, soreness, and difficulty swallowing.
Choice D reason:
Halitosis, or bad breath, is not an infectious condition and is not directly associated with a decreased CD4+ T-cell count. It can result from various factors, including oral hygiene, diet, or underlying health conditions, but it is not a specific concern related to HIV/AID.
Correct Answer is C
Explanation
Choice A reason:
Bradycardia, which is a slower than normal heart rate, is not typically associated with diabetes insipidus. Diabetes insipidus primarily affects the kidneys and fluid balance in the body, leading to frequent urination and thirst but not directly affecting heart rate.
Choice B reason:
Moist mucous membranes are not expected in diabetes insipidus. In fact, due to excessive urination, a person with diabetes insipidus is more likely to experience dry mucous membranes from dehydration unless they are adequately hydrating.
Choice C reason:
Urine specific gravity 1.002 is a key finding in diabetes insipidus. This condition is characterized by the excretion of large amounts of dilute urine with low specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030⁴. A value of 1.002 indicates very dilute urine, which is consistent with the inability of the kidneys to concentrate urine in diabetes insipidus.
Choice D reason:
Bounding peripheral pulses are not a finding associated with diabetes insipidus. Bounding pulses may be associated with other conditions such as fever, anemia, or hyperthyroidism but not typically with diabetes insipidus.
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