Question

A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client:

Select all that apply:

a.) Rapid shallow respirations.
b.) Severe hypotension.
c.) Mental status changes.
d.) Elevated temperature.
e.) Lactic acidosis.
f.) Oliguria.

Answer 1

A nurse assessing a sepsis client is likely to observe symptoms such as rapid shallow respirations, severe hypotension, mental status changes, elevated temperature, lactic acidosis, and oliguria, reflecting the systemic inflammatory response and potential organ dysfunction.

Step-by-step explanation:

When assessing a client diagnosed with sepsis, a nurse is likely to find several clinical manifestations due to the systemic inflammatory response that occurs. The signs and symptoms selected that are commonly associated with sepsis include:

• Rapid shallow respirations: Often seen as the body attempts to compensate for metabolic acidosis and maintain oxygenation.
• Severe hypotension: A result of vasodilation and increased vascular permeability, which can lead to septic shock.
• Mental status changes: Due to the effects of toxins and inflammation on the brain.
• Elevated temperature: Fever is a common response to infection and systemic inflammation.
• Lactic acidosis: Occurs due to inadequate oxygenation at the cellular level and the shift to anaerobic metabolism.
• Oliguria: A result of reduced kidney perfusion due to hypotension and may indicate acute kidney injury.

These symptoms are critical indicators of the body's response to a severe infection that has triggered an overwhelming and dysregulated immune reaction, leading to systemic inflammation and potential organ dysfunction.