A client with sepsis has been admitted to the unit. The primary nurse is planning care and determines that one goal for this client is to maintain normal mental status
Which of the following evaluations by the nurse imply that the goal has been met? 1. The client has a Glasgow coma score of 4.
2. The client's pupils are fixed.
3. The client is restless.
4. The client responds to questions appropriately.
4. The client responds to questions appropriately.
Rationale:
A client who responds to questions appropriately is alert. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent. Restlessness in a client with sepsis can be a sign that the client's condition is deteriorating.
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