A nurse is assessing a client who has an infection.
Which of the following findings is a manifestation of sepsis? (Select all that apply.)
Hypertension.
Hypoglycemia.
Altered mental status.
Elevated WBC count.
Vomiting.
Correct Answer : C,D,E
Choice A rationale
Hypertension is not a typical manifestation of sepsis; sepsis usually involves hypotension.
Choice B rationale
Hypoglycemia is not a common manifestation of sepsis; hyperglycemia is more typical.
Choice C rationale
Altered mental status can occur due to the systemic inflammation and infection affecting the brain.
Choice D rationale
An elevated WBC count indicates an immune response to infection, which is a common sign of sepsis.
Choice E rationale
Vomiting can occur due to the body's response to the infection and systemic inflammation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Acetaminophen can be hepatotoxic in clients with liver damage, so it should be avoided. This is especially critical for clients with cirrhosis, where liver function is already compromised.
Choice B rationale
Eating three large meals can be overwhelming for someone with cirrhosis, as the liver is less able to process nutrients efficiently. Smaller, more frequent meals are advised.
Choice C rationale
Avoiding high-sodium foods is crucial because cirrhosis often leads to fluid retention and ascites, which can be exacerbated by a high-sodium diet.
Choice D rationale
Increasing activity as much as possible may not be safe for someone with cirrhosis, who often experiences fatigue and muscle wasting. Activity should be balanced with rest and tolerance levels.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Implementing a low-sodium diet helps reduce fluid retention and ascites in clients with cirrhosis, improving their condition.
Choice B rationale
Furosemide is a diuretic that helps reduce fluid overload and ascites in clients with cirrhosis by promoting excretion of excess fluid.
Choice C rationale
Warfarin is an anticoagulant and is not typically used in the management of cirrhosis as it could increase the risk of bleeding complications, especially in clients with liver dysfunction.
Choice D rationale
Measuring the client's abdominal girth is crucial for monitoring the progression of ascites, a common complication of cirrhosis.
Choice E rationale
Encouraging weight lifting is not advisable as it can exacerbate varices and increase the risk of bleeding in clients with cirrhosis.
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