A nurse is assessing a client who has septic shock. The nurse notes that the client has a blood pressure of 80/50 mmHg, a heart rate of 120 beats per minute, a respiratory rate of 28 breaths per minute, and a temperature of 39°C.
The nurse calculates that the client has a Sequential Organ Failure Assessment (SOFA) score of what value?
1
4
6
8
Provide supplemental oxygen as needed
The Correct Answer is A
The SOFA score is a tool that assesses the degree of organ dysfunction or failure in septic shock. It is based on six parameters: blood pressure, Glasgow coma scale, PaO2/FiO2 ratio, platelet count, bilirubin level, and creatinine level. Each parameter is assigned a score from 0 to 4 based on the severity of the abnormality. The total SOFA score ranges from 0 to 24, with higher scores indicating worse organ dysfunction or failure.
The client's blood pressure of 80/50 mmHg corresponds to a SOFA score of 1, as it indicates hypotension.
The client's Glasgow coma scale is not given, so it is assumed to be normal (15), which corresponds to a SOFA score of 0.
The client's PaO2/FiO2 ratio is not given, so it is assumed to be normal (>400), which corresponds to a SOFA score of 0.
The client's platelet count is not given, so it is assumed to be normal (>150 x 10^9/L), which corresponds to a SOFA score of 0.
The client's bilirubin level is not given, so it is assumed to be normal (<20 micromol/L), which corresponds to a SOFA score of 0.
The client's creatinine level is not given, so it is assumed to be normal (<110 micromol/L), which corresponds to a SOFA score of 0.
The total SOFA score is the sum of the scores for each parameter: 1 + 0 + 0 + 0 + 0 + 0 = 1. Therefore, the client has a SOFA score of 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Gram-positive cocci are bacteria that have a spherical shape and stain purple with Gram stain due to their thick peptidoglycan cell wall. Streptococcus pyogenes is an example of gram-positive cocci that can cause infections such as pharyngitis, impetigo, cellulitis, necrotizing fasciitis, or rheumatic fever.
Choice B reason:
Gram-negative cocci are bacteria that have a spherical shape and stain pink with Gram stain due to their thin peptidoglycan cell wall and outer membrane. Neisseria gonorrhoeae and Neisseria meningitidis are examples of gram-negative cocci that can cause infections such as gonorrhea, meningitis, or septicemia.
Choice C reason:
Gram-positive bacilli are bacteria that have a rod-shaped shape and stain purple with Gram stain due to their thick peptidoglycan cell wall. Bacillus anthracis and Clostridium botulinum are examples of gram-positive bacilli that can cause infections such as anthrax, botulism, or tetanus.
Choice D reason:
Gram-negative bacilli are bacteria that have a rod-shaped shape and stain pink with Gram stain due to their thin peptidoglycan cell wall and outer membrane. Escherichia coli and Pseudomonas aeruginosa are examples of gram-negative bacilli that can cause infections such as urinary tract infection, wound infection, or sepsis.
Correct Answer is C
Explanation
Choice A reason:
Type I hypersensitivity is not involved in RA, as it does not involve IgE antibodies or mast cells.
Choice B reason:
Type II hypersensitivity is not involved in RA, as it does not involve IgG or IgM antibodies or target cells.2
Choice C reason:
RA is caused by type III hypersensitivity, which involves the formation and deposition of immune complexes in the synovial membranes of the joints. This triggers complement activation, inflammation, and tissue damage.
Choice D reason:
Type IV hypersensitivity is not involved in RA, as it does not involve cytotoxic T cells or helper T cells.
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