A nurse is assisting with the care of a preschooler who sustained a major burn injury 5 days ago. Which of the following findings should the nurse identify as a manifestation of sepsis?
Polyuria
Disorientation
Hyperactive bowel sounds
Hypoglycemia
The Correct Answer is B
A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Covering the scale with a clean sheet of paper is unnecessary and does not affect the accuracy of the weight or length measurement.
B. Measuring the infant's length from the crown of the head to the heels of the feet is the correct method for obtaining length measurements in infants.
C. Placing a stadiometer on the top of the infant's head is incorrect; the measurement should be taken from head to heel.
D. Ensuring the scale is balanced to "0" before weighing the infant is essential for obtaining an accurate weight measurement.
E. Obtaining the infant's weight with their diaper on may add unnecessary weight, potentially affecting the accuracy of the weight measurement.
Correct Answer is B
Explanation
A. The sensor should be applied to a site where it can provide accurate readings, but not specifically to the fingernail.
B. Repositioning the probe every 2 hours helps prevent skin irritation and ensures accurate readings.
C. Warming the skin prior to probe placement is not necessary and is not standard practice unless the client has circulatory compromise.
D. Taping the wire to the palm of the hand is not necessary and may cause discomfort or interfere with accurate readings.
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