A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Vomiting Hypoglycemia

Hypertension

Altered mental status

Elevated WBC’s count

Answer and Explanation

The Correct Answer is C

A.   Vomiting is not a specific manifestation of sepsis.
B.   Hypertension is not a typical finding in sepsis; hypotension is more common.
C.   Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D.   While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.

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Correct Answer is D

Explanation

A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.
B. This statement may indicate frustration with physical therapy progress but does not directly address body image.
C. This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D. This statement directly addresses the client's perception of their body image following the amputation.

A. Dry the prosthesis socket completely before applying it to the limb. B. Apply a moisturizing lotion or oil to the stump daily. C. Keep the prosthesis in direct contact with the residual limb. D. Expect some skin irritation from the prosthesis.

Correct Answer is A

Explanation

A. Ensuring the prosthesis socket is dry helps prevent skin irritation, discomfort, and the potential for infection.
B. Applying moisturizing lotion or oil can make the skin too slippery, affecting the fit and function of the prosthesis.
C. The prosthesis should not be in direct contact with the residual limb; a liner or sock is typically worn.
D. Skin irritation should be minimized, and any persistent issues should be addressed with the prosthetist. Expecting irritation as a norm is not appropriate.

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A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about prosthesis care for a client following a below-the- knee amputation. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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