An older adult client with sepsis has been admitted to the nursing unit. The nurse is planning care and determines that one goal for this client is to maintain normal mental status
Which outcome evaluation implies that the goal has been met?
A) The client is agitated.
B) The client has a Glasgow coma score of 4.
C) The client responds to questions appropriately.
D) The client's pupils are fixed and dilated.
Answer: C
A client who responds to questions appropriately is alert and oriented. Restlessness or agitation in a client with sepsis can be a sign that the client's condition is deteriorating. The client with a Glasgow coma score of 4 is comatose. When pupils are fixed and do not respond to light, death is imminent.
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