The nurse is caring for a client with systemic inflammatory response syndrome (SIRS). Which assessment finding would the nurse anticipate? Select all that apply.
A) A white blood cell (WBC) count less than 3,000 cells/mm3 or greater than 10,000 cells/mm3
B) A heart rate of greater than 90 beats per minute
C) A respiratory rate of greater than 16 respirations per minute
D) A body temperature of less than 36°C or greater than 38°C
E) The presence of greater than 20% immature neutrophils
A) A white blood cell (WBC) count less than 3,000 cells/mm3 or greater than 10,000 cells/mm3
B) A heart rate of greater than 90 beats per minute
D) A body temperature of less than 36°C or greater than 38°C
Explanation: A) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3) or the presence of greater than 10% immature neutrophils.
B) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils.
C) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils.
D) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils.
E) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils.
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