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. Limiting the number of health care workers entering the room helps reduce the risk of exposure to infections.
B. Inserting an indwelling catheter is not a routine intervention for immunosuppressed clients and may increase the risk of infection.
C. Monitoring temperature more frequently than once per shift is crucial to detect early signs of infection in immunosuppressed clients.
D. Fresh fruit may carry a risk of bacterial contamination, and caution should be exercised in providing it to immunosuppressed clients.

A. The client draws his legs up into a fetal position. B. The facial muscles relax. C. The respiratory rate increases. D. The shoulders droop. E. The pulse is within the expected range

Correct Answer is ["B","D","E"]

Explanation

A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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