The nurse is caring for a client with suspected sepsis. What actions will the nurse take within one hour of the client being identified as being at risk for sepsis? (Select all that apply)

Choice A reason: This response is dismissive, impatient, and judgmental. It fails to validate the patient’s experience and ignores the fact that phantom limb pain is a documented neurological phenomenon that requires appropriate clinical management rather than just "acceptance" by the patient.

Choice B reason: Phantom limb pain is a very real sensation experienced by many amputees due to the reorganization of the somatosensory cortex. The nurse's first action should always be a thorough assessment. Asking the patient to describe the pain helps determine its quality, intensity, and appropriate pharmacological interventions.

Choice C reason: While non-pharmacological interventions like imagery or mirror therapy can be helpful in managing phantom limb pain, the nurse must first perform a complete assessment of the pain. Offering a solution before fully understanding the nature of the pain is premature and skips a vital step.

Choice D reason: This statement is medically incorrect and highly unprofessional. Telling a patient their pain "does not exist" is gaslighting. Phantom limb pain is a complex physiological and psychological condition caused by genuine nerve signaling in the brain and spinal cord, regardless of the limb's absence.

Choice A reason: Administering pain medication might be appropriate if the patient reports pain, but the nurse must first determine the cause of the physiological changes. Pain is only one possible reason for tachycardia and tachypnea; other causes include hemorrhage, sepsis, or pulmonary embolism that require different treatments.

Choice B reason: Simply documenting the findings is insufficient. The patient is showing a trend of physiological instability with increasing heart and respiratory rates. Nursing responsibility includes analyzing these trends and performing a more comprehensive assessment to catch potential complications before they escalate into a crisis.

Choice C reason: The Modified Early Warning Score (MEWS) is a validated clinical tool used to identify patients at risk for clinical deterioration. By calculating a score based on vital signs and consciousness, the nurse can objectively determine if a higher level of care or physician notification is required for this patient.

Choice D reason: Increasing the IV infusion rate without a specific order or a clear diagnosis of hypovolemia is outside the nurse’s scope of practice. It could also be harmful if the patient’s symptoms are related to cardiac strain or fluid overload rather than a deficit in intravascular volume.