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 A

Explanation

A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.A. Listening to music is a form of distraction, diverting the client's attention away from pain.
B. Biofeedback involves using electronic monitoring to help individuals gain conscious control over physiological processes, not applicable in this context.
C. Guided imagery involves using the imagination to create calming mental images, not directly related to listening to music.
D. Meditation involves a state of focused attention and may not be as directly applicable during a medical procedure.
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. Use a new sponge each time the surgical site is scrubbed. B. Cleanse the surgical site with a povidone-iodine solution. C. Shave the client’s hair near the surgical site. D. Scrub the surgical site starting at the outer edge and moving inwards

Correct Answer is A

Explanation

A. This is because using the same sponge repeatedly can introduce bacteria and other contaminants to the surgical site, increasing the risk of infection.
B. Cleansing the surgical site with a povidone-iodine solution is not recommended because it can cause skin irritation and allergic reactions. The nurse should use a chlorhexidine-based antiseptic solution instead, which is more effective and less toxic.
C. Shaving the client's hair near the surgical site is generally avoided, as it can increase the risk of infection. Hair removal, if needed, is often done with clippers.
D. The surgical site should be scrubbed starting at the center and moving outwards in a circular motion.

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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?

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