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:
Arthralgia, or joint pain, is a common symptom associated with heterotopic ossification (HO), especially when it occurs near joints. The ectopic bone formation can lead to restricted movement and pain during joint movement.

Choice B reason:
Bradycardia, or a slower than normal heart rate, is not directly associated with HO. While spinal cord injuries can affect autonomic control and potentially lead to bradycardia, it is not a symptom specifically linked to the presence of HO.

Choice C reason:
Fecal impaction may occur in patients with spinal cord injuries due to mobility issues and changes in bowel function, but it is not a direct result of HO. HO does not typically affect bowel movements unless the ossification is in a location that mechanically obstructs the bowel.

Choice D reason:
Hypertension, or high blood pressure, is not a symptom commonly associated with HO. While individuals with spinal cord injuries may experience dysregulation of blood pressure, this is not specifically related to HO.

A. "The medication will decrease manifestations but not cure the infection." B. "I need to take all the antibiotics, as prescribed, to treat the infection." C. "If I don't have any lesions, I can't transmit the infection to my partner." D. "Once I finish the medication, my partner is not at risk for getting the infection."

Correct Answer is A

Explanation

Choice A reason:
This statement is correct. Medications for genital herpes, such as antiviral drugs, can help decrease the severity and frequency of symptoms but do not cure the infection. The herpes simplex virus remains in the body and can cause recurrent outbreaks.

Choice B reason:
This statement is incorrect and indicates a misunderstanding. Genital herpes is caused by the herpes simplex virus and cannot be treated with antibiotics, which are effective only against bacterial infections. Antiviral medications are used to treat viral infections like genital herpes.

Choice C reason:
This statement is incorrect. Genital herpes can be transmitted to a partner even when lesions are not present. The virus can be shed from the skin even without visible symptoms, a process known as asymptomatic viral shedding.

Choice D reason:
This statement is incorrect. Even after finishing a course of medication, the risk of transmitting genital herpes to a partner remains because the virus persists in the body. Safe sex practices, including the use of condoms, can help reduce the risk of transmission.

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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)

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a spinal cord injury with heterotopic ossifications. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is teaching a client who has genital herpes about the physiological effects of the infection. Which of the following statements by the client indicates that the teaching has been effective?

Correct Answer is A

Explanation

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