The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider prescribes a sepsis protocol to be initiated.
Which intervention is most important for the nurse to include in the plan of care?

Choice A rationale:

Addiction involves a dependence on a substance or behavior that leads to withdrawal symptoms when the substance or behavior is discontinued. The client's handwashing behavior is not related to addiction.

Choice B rationale:

Phobia refers to an irrational and intense fear of a specific object or situation. While the client's avoidance of sitting on chairs in the day area may be related to anxiety, it does not represent a specific phobia.

Choice C rationale:

Compulsion is the correct answer because the client's handwashing ritual is an example of compulsive behavior. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rigid rules. In this case, the client is compelled to engage in the ritual to alleviate anxiety or distress.

Choice D rationale:

Obsession refers to persistent and intrusive thoughts, urges, or images that cause distress and anxiety. While the client's handwashing ritual may be related to obsessive thoughts about cleanliness, the primary clinical behavior being exhibited is the compulsive handwashing itself.

Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of Stroke as evidenced by Neurological defects and Garbled speech. The symptoms of facial drooping, garbled speech, and high blood pressure are common signs of a stroke. However, it’s important to get a professional medical diagnosis as soon as possible. Please seek immediate medical attention.

Choice A rationale:

Intoxication is a plausible explanation for the client’s symptoms, especially given the report of alcohol consumption. However, intoxication typically does not cause facial drooping, which is a common sign of neurological issues such as a stroke. Therefore, while intoxication may contribute to the client’s condition, it is not the most likely primary cause.

Choice B rationale:

Stroke is a medical emergency that often presents with facial drooping and garbled speech, both of which are observed in this client. A stroke occurs when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. This can lead to brain cells dying in minutes. The client’s high blood pressure (210/98 mm Hg) is a significant risk factor for stroke. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg.

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.