The nurse is assessing a patient for severe sepsis. Which finding indicates the patient is developing this health problem?
1. Decreased capillary filling and mottling
2. Fever and decreased urine output
3. Hypotension and lactic acidosis
4. Increased glomerular filtration rate and increased D-dimer levels
3
Rationale 1: Decreased capillary filling and mottling are both related to sepsis instead of severe sepsis.
Rationale 2: Fever and decreased urine output are both related to sepsis instead of severe sepsis.
Rationale 3: The best description of severe sepsis is hypotension and lactic acidosis. These signs also represent altered cellular metabolism, which results in organ dysfunction.
Rationale 4: In severe sepsis a decreased, rather than increased, glomerular filtration rate would be expected.
You might also like to view...
A nurse is assessing a client's ability to learn. Which of the following would be most important for the nurse to consider? Select all that apply
A) Literacy level B) Language C) Presence of a learning impairment D) Visual impairment E) Hearing impairment
Classify the following arterial blood gas: pH = 7.52, PaCO2 = 30 mm Hg, HCO3- = 24 mEq/L.
A) Metabolic acidosis. B) Metabolic alkalosis. C) Respiratory acidosis. D) Respiratory alkalosis.
An elderly client tells the nurse that he does not have the same appetite as he did when younger and often has problems "moving his bowels."
The nurse realizes that as a normal change associated with aging of the gastrointestinal tract, the older client is more prone to experience: a. increased sensitivity to taste. c. increased peristalsis. b. increased saliva production. d. likelihood for constipation.
While exiting a burning building, a patient's eyebrows and lashes were burned. What should the nurse suspect this patient might experience?
A. Itchiness as the hair grows back B. Wound infections C. Foreign bodies in the eyes D. Fluid and electrolyte imbalance