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 B
Explanation
A. Corticosteroid ointment is not recommended for viral conjunctivitis as it can exacerbate the infection or prolong the healing process. Viral conjunctivitis typically resolves on its own without the need for corticosteroids.
B. Cleaning the eye by wiping downward and outward from the inner canthus helps to remove discharge and prevent the spread of infection. This technique ensures that contaminants are removed efficiently and reduces the risk of re-infection.
C. Antibiotic eye ointment is not indicated for viral conjunctivitis, as antibiotics are ineffective against viruses. Treatment typically focuses on symptom relief rather than antibacterial therapy.
D. While cool compresses can provide symptom relief, continuous application is not necessary. Intermittent cool compresses may help to soothe irritation and reduce swelling, but continuous use is not required.
Correct Answer is C
Explanation
A. BUN level of 12 mg/dL is within normal range and does not indicate infection.
B. Urine specific gravity of 1.014 is within normal range and does not indicate infection.
C. A WBC count of 17,500/µL is elevated and indicates a possible infection, which should be reported immediately.
D. Urine osmolality of 500 mOsm/kg is within normal range and does not indicate infection.
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