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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

WBC count 17,000/mm3: Indication of Potential Improvement. The initial WBC count was 22,000/mm3, and 24 hours later, it has decreased to 17,000/mm3, indicating improvement.

Steatorrhea: Unrelated to Diagnosis. This symptom is typically associated with cystic fibrosis rather than pneumonia.

Oxygen saturation 95% on 1 L oxygen via nasal cannula: Indication of Potential Improvement. The decrease in oxygen requirement from 2 L to 1 L suggests the adolescent's respiratory status may be improving.

Barrel chest: Unrelated to Diagnosis. This physical finding is more indicative of chronic conditions such as cystic fibrosis rather than an acute pneumonia presentation.

Hemoptysis 300 mL: Indication of Potential Worsening Condition. The presence of significant hemoptysis indicates a worsening condition, possibly due to progression or complications of pneumonia.

Respiratory rate 32/min: Indication of Potential Improvement. The decrease in respiratory rate from 36/min to 32/min suggests a possible improvement in respiratory status.

A. Shares toys with others readily B. Has an imaginary playmate C. Demonstrates parallel play D. Asks many questions

Correct Answer is C

Explanation

A. Sharing toys readily is more common in older preschoolers and school-age children.
B. Having an imaginary playmate typically occurs in children slightly older than 24 months.
C. Parallel play, where children play alongside each other without interacting, is typical for toddlers around 24 months.
D. Asking many questions is more characteristic of preschool-aged children.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

A nurse is planning care for a 24-month-old child. Which of the following developmental characteristics should the nurse consider when planning care for the child?

Correct Answer is C

Explanation

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