Which assessment findings should cause a nurse to be concerned that a patient is developing severe sepsis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply

Question

1. Serum creatinine level 2.0 md/dL
2. Absent bowel sounds
3. Onset of confusion
4. Heart rate 54
5. Blood pressure 148/90 mm Hg

Answer 1

1,2,3
Rationale 1: In severe sepsis, renal dysfunction is evidenced by an increase in serum creatinine greater than 0.5 mg/dL.
Rationale 2: Gastrointestinal effects of severe sepsis are evidenced by absent bowel sounds or ileus.
Rationale 3: Neurological dysfunction of severe sepsis is indicated by a sudden change in mental status with possible confusion.
Rationale 4: Tachycardia (not bradycardia) is a cardiovascular effect of severe sepsis.
Rationale 5: Hypotension (not hypertension) is a cardiovascular effect of severe sepsis.