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 C

Explanation

A. Shock typically results in tachycardia as the body compensates for decreased perfusion.
B. In shock, there is often decreased urine output due to decreased perfusion to the kidneys.
C. A hallmark sign of shock is low blood pressure as a result of inadequate tissue perfusion.
D. Bowel sounds may be diminished rather than hyperactive in cases of shock.

A. Instruct client to use an incentive spirometer every 4 hr. B. Place the client in a room with negative-pressure airflow. C. Serve cooked fruit with meals. D. Report temperatures greater than 39.5 C (102.3 F lasting more than 4 hr.)

Correct Answer is D

Explanation

A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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