Patient Data
Following the healthcare provider's diagnosis of systemic inflammatory response syndrome (SIRS), the nurse is considering client's risk factors.
Drag one condition and one finding to complete the sentence.
The nurse recognizes that the systemic inflammatory response syndrome (SIRS) has a high risk of transitioning to
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Rationale:
• Multiple organ dysfunction syndrome (MODS): SIRS can progress to multiple organ dysfunction syndrome if the inflammatory response becomes uncontrolled, leading to tissue hypoperfusion and organ failure. The client shows risk factors including advanced age, recent surgery, infection at the surgical site, and confusion. Early identification and monitoring are essential to prevent progression from systemic inflammation to MODS.
• Lactate level: Elevated lactate levels indicate tissue hypoxia and poor perfusion, serving as an early marker for sepsis progression and organ dysfunction. Monitoring lactate allows timely interventions to restore perfusion and prevent progression to MODS. Lactate trends provide objective data to assess the severity of systemic inflammatory response and effectiveness of therapy.
• Anemia: While anemia can complicate critical illness, it is not the primary risk associated with SIRS. The client’s hemoglobin is slightly low (12.2 g/dL) but does not explain systemic inflammation or risk for organ failure.
• Cardiogenic shock: Cardiogenic shock results from primary cardiac pump failure, which is not evident in this client. Vital signs show hypotension is mild, and there is no history of acute cardiac compromise. The main concern with SIRS is systemic inflammation progressing to MODS rather than isolated cardiac shock.
• Temperature: While fever is a defining criterion for SIRS, it is already accounted for in the initial diagnosis. Temperature monitoring alone does not reliably indicate progression to organ dysfunction. Lactate levels provide a more specific measure of tissue hypoperfusion and risk of MODS.
• Hemoglobin level: Hemoglobin monitoring assesses oxygen-carrying capacity but does not reflect systemic perfusion or inflammatory severity. While relevant for overall health, it does not provide early warning of SIRS progression to organ failure like lactate levels do.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Medicate for pain prior to moving the client: Pain control improves comfort and cooperation during transport, but it does not directly prevent a life-threatening complication related to chest tube function during movement.
B. Keep the drainage system below the insertion site: Maintaining the drainage system below chest level prevents backflow of air or fluid into the pleural space, which could cause a pneumothorax or compromise lung re-expansion during transport.
C. Send the client to radiology via stretcher: A stretcher is appropriate for safety, but it does not address the priority risk associated with chest tube mechanics and pleural pressure changes.
D. Mark the drainage amount on the collection chamber: Tracking output is important for ongoing assessment, but it is not the most immediate intervention required to ensure chest tube safety during transport.
Correct Answer is ["A","B","F"]
Explanation
Rationale:
A. Arousable only by painful stimuli: Reduced level of consciousness in a client with a subarachnoid hemorrhage indicates potential increased intracranial pressure (ICP) or neurological deterioration. Immediate monitoring and intervention are critical to prevent further brain injury.
B. Does not follow commands: The inability to follow commands reflects altered neurologic status and may indicate worsening cerebral perfusion or progressing neurological compromise. This finding requires urgent assessment and continuous monitoring.
C. Temperature 98.4°F (36.9° C): This is within normal limits and does not pose immediate risk. Mild temperature variations are not acutely concerning in the context of neurological compromise.
D. Blood pressure 136/81 mm Hg: Although slightly elevated, this blood pressure is not immediately life-threatening. Continuous monitoring is indicated due to the risk of rebleeding or increased ICP, but it is not the most urgent concern at this time.
E. Laceration left foot that is 2.4" (6 cm) long: While it requires wound care, this laceration is not life-threatening compared with the client’s acute neurological status. Immediate attention focuses on stabilizing intracranial pathology first.
F. Pupils are 6 mm and sluggish: Dilated, sluggish pupils indicate possible increased ICP or impending brain herniation. This is a critical neurologic finding that requires immediate assessment and intervention.
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