A nurse is assessing the vital signs for a 10-year old child following a burn injury. Which of the following clinical manifestations indicate early septic shock?

Urinary output 100 mL/hr

Temperature 39.1C (102.4° F)

Blood pressure 130/90 mm Hg

Heart ráte 60/min

Answer and Explanation

The Correct Answer is B

A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.

B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.

C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.

D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.

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Correct Answer is A

Explanation

A. The nurse should notify the charge nurse of the situation to ensure that the client’s legal rights, autonomy, and best interests are considered in making decisions regarding treatment.

B. Offering an antiemetic is not the primary concern when the client is refusing treatment; the issue is the refusal of care.

C. Administering a sedative without addressing the underlying issue would not be appropriate and could violate the adolescent’s autonomy.

D. Starting the IV per the parent's request without the adolescent’s consent may violate the adolescent’s rights and should not be done without careful consideration of legal and ethical principles.

A. A toddler who has a concussion and an episode of forceful vomiting B. An adolescent who was placed into halo traction 1 hr ago and rates his pain at a 6 on a 0 to 10 scale C. A school-age child who has acute glomerulonephritis and brown-colored urine D. An adolescent who has infective endocarditis and reports having a headache

Correct Answer is A

Explanation

A. Forceful vomiting in a child with a concussion could indicate increased intracranial pressure (ICP), which is a medical emergency. Vomiting is a common symptom of ICP, and prompt assessment is necessary to determine the severity of the concussion and prevent further complications.

B. Pain following halo traction is expected, and a pain score of 6 is moderate. The pain can be managed with appropriate interventions, and it does not indicate an immediate life-threatening situation.

C. Brown-colored urine in acute glomerulonephritis is concerning for hematuria, but it typically develops over several days and is not an acute emergency.

D. A headache in a patient with infective endocarditis could indicate a potential complication such as embolism or increased intracranial pressure, but it is not as immediately life-threatening as the signs of a concussion.

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