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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Elevating the head of the client's bed to 45° during meals helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the airway.
B. Instructing the client to tilt their head back while swallowing is not recommended, as it may increase the risk of aspiration.
C. Turning on the television during meals is unrelated to reducing the risk of aspiration pneumonia.
D. Providing the client with oral hygiene is important for overall health but does not specifically address the risk of aspiration pneumonia.

A. "Let's talk about what activities you are going to participate in tomorrow." B. "This is something you should discuss with your parents when they return." C. "You need to focus on getting better instead of what may or may not happen." D. "Let's talk about it. Tell me more about what you are thinking."

Correct Answer is D

Explanation

A. Avoids the child's question and deflects to a future topic.
B. Defers the conversation and may not address the child's immediate concerns.
C. Minimizes the child's feelings and concerns about the future.
D. Encourages open communication and allows the child to express feelings and fears.

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A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

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Naxlex Comprehensive Predictor Exams

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Explanation

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