A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

Rationale:

• Antibiotic: Administering an antibiotic addresses the underlying infection, which is likely causing the fever, low blood pressure, and altered mental status. Prompt antibiotic treatment reduces the risk of progression to septic shock. Early intervention improves patient outcomes in suspected sepsis.

• Antipyretic: An antipyretic helps reduce fever but does not treat the underlying infection. Lowering the temperature alone would not address the systemic inflammatory response seen in sepsis. This option does not prevent clinical deterioration.

• Anti-anxiety medication: An anti-anxiety medication may temporarily calm the patient but can worsen confusion and mask signs of deterioration. It does not treat the infection or improve hemodynamic status. This is inappropriate in suspected sepsis.

• Suspected surgical site infection and sepsis: The inflamed, draining surgical wound, fever, hypotension, and high WBC strongly indicate a developing infection. Mental status changes are also typical in sepsis. This makes infection the most urgent concern requiring antibiotic therapy.

• Elevated temperature and heart rate: While these signs are concerning, they are common with many conditions and not specific to sepsis. They are part of the clinical picture but not the driving reason for immediate antibiotic treatment.

• History of Parkinson’s disease and confusion: The confusion may partly relate to Parkinson’s or sensory impairment, but acute mental status changes with fever and hypotension suggest sepsis. Parkinson’s is chronic and not the immediate priority.

Rationale:

• Pneumonia: The child’s shallow respirations, diminished breath sounds at the bases, and ongoing refusal to use the incentive spirometer suggest decreased lung expansion and poor airway clearance. These are classic risk factors for postoperative pneumonia, especially in pediatric clients who are reluctant to engage in deep breathing exercises.
• Peritonitis: Peritonitis would be indicated by signs such as a rigid abdomen, rebound tenderness, or marked fever. The client has mild abdominal tenderness but not the severity or systemic signs expected with peritonitis.
• Wound infection: There are no signs of wound infection. The surgical dressing is consistently described as dry and intact with no redness, drainage, or swelling, which are typical indicators of infection.
• Temperature: The child's temperature is slightly elevated but remains within the low-grade range and does not independently indicate a serious complication. It’s not the most significant factor in this case.
• Bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery and do not directly point to a respiratory complication. They are improving postoperatively and are not a primary concern for pneumonia.
• Breathing effort: The child’s consistently shallow respirations and diminished breath sounds show a risk for poor ventilation. These are warning signs for the development of postoperative pneumonia.
• Abdominal tenderness: Mild to moderate tenderness is expected 1 day after abdominal surgery and shows improvement over time. It is not strongly suggestive of a new or worsening condition like pneumonia.
• Refusal to use incentive spirometer: Using the incentive spirometer encourages deep breathing and lung expansion. Refusing it increases the risk of atelectasis and subsequent pneumonia, especially in pediatric clients with shallow breathing patterns.
• Surgical dressing: The dressing is consistently described as dry and intact with no signs of infection or complication. It does not point to any current or developing risk.