A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)

A client who has a temperature of 37.2°C (99°F) and a heart rate of 88/min.

A client who has a heart rate of 132/min and a respiratory rate of 30/min.

A client who has a decrease in level of consciousness and a heart rate greater than 130/min.

A client who has bradypnea and a white blood cell (WBC) count of 10,000/mm³ (normal range: 5,000 to 10,000/mm³).

A client who has a temperature of 36°C (96.8°F) and a respiratory rate of 16/min.

Answer and Explanation

Correct Answer : B,C

Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.

Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.

Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.

Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.

Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.

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Correct Answer is A

Explanation

Choice A reason:

Babinski's sign is a neurological reflex that's tested by stroking the sole of the foot. A positive Babinski's sign, which is normal in infants but abnormal in adults, is indicated by dorsiflexion of the great toe (the toe points up) while the other toes fan out. This reflex suggests dysfunction of the corticospinal tract, which may be due to various neurological conditions. In the context of a stuporous patient with an unrepaired femur fracture, a positive Babinski's sign could indicate an acute neurological change possibly related to the injury or a secondary complication such as a fat embolism syndrome, which can occur after fractures and may affect the brain.

Choice B reason:

Pronation of the arms is not associated with Babinski's sign. Pronation is a rotational movement where the hand and upper arm are turned inwards. While arm movements are part of the neurological examination, they do not constitute a response to the plantar reflex test used to elicit Babinski's sign.

Choice C reason:

Pinpoint pupils may indicate opioid overdose or damage to the pons due to various causes, but they are not a component of Babinski's sign. Pupil size and reaction to light are important in neurological assessments, but they are separate from the reflexes tested by the Babinski sign.

Choice D reason:

Jerking contractions of the head and neck are not related to Babinski's sign. These could be indicative of seizure activity or other neurological disorders but are not a response to the plantar reflex test.

A. Free T4 B. Thyroid stimulating hormone (TSH) C. Serum T3 D. Serum T4

Correct Answer is B

Explanation

Choice A reason:
In primary hypothyroidism, the thyroid gland is underactive and does not produce sufficient thyroid hormones, including Free T4. Therefore, we would not expect an elevation of Free T4 in primary hypothyroidism; instead, its levels would typically be low or normal.

Choice B reason:
Thyroid stimulating hormone (TSH) levels are elevated in primary hypothyroidism because the pituitary gland releases more TSH in an attempt to stimulate the thyroid gland to produce more thyroid hormones. This is a compensatory response to the low levels of circulating thyroid hormones, particularly thyroxine (T4).

Choice C reason:
Serum T3 levels may be low or normal in primary hypothyroidism. T3 is the active form of thyroid hormone and is usually converted from T4. If T4 levels are low, T3 levels may also be affected; however, T3 levels are not the primary diagnostic marker for hypothyroidism and do not typically show elevation in this condition.

Choice D reason:
Serum T4 levels are typically low in primary hypothyroidism because the thyroid gland is not producing enough of this hormone. An elevation of serum T4 would not be expected unless the patient is receiving treatment for hypothyroidism.

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A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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