A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?
Vomiting Hypoglycemia
Hypertension
Altered mental status
Elevated WBC’s count
The Correct Answer is C
A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The dosage of opioid narcotics is not unlimited and should be carefully titrated to the client's pain level.
B. Opioid narcotics are not restricted solely due to the risk of addiction, especially in end-of-life care where effective pain management is a priority.
C. This statement emphasizes the importance of maintaining a stepwise approach to pain management, preserving options for effective pain control.
D. The use of opioid narcotics is not restricted solely to when death is imminent; it depends on the client's pain and symptom management needs.
Correct Answer is B
Explanation
A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.
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