The nurse is concerned that a 10-year-old patient injured in a motor vehicle accident may be developing septic shock
Which assessment findings would support this concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The heart rate is 120 bpm sustained.
2. The patient has thready peripheral pulses.
3. The patient is crying.
4. Capillary refill is 2 seconds.
5. The patient has diarrhea.
1,2
Rationale 1: Sustained tachycardia is an assessment finding associated with septic shock in the pediatric patient.
Rationale 2: Changes in peripheral pulses may indicate shock in the pediatric patient.
Rationale 3: Anxiety and pain may result in crying. This is a normal response.
Rationale 4: Capillary refill longer than 2 seconds may indicate poor perfusion and shock.
Rationale 5: The nurse would be concerned that the patient has developed diarrhea, but this is not a specific indicator of septic shock.
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