A client with sepsis has been admitted to the unit. The primary ...

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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.

Question 2

An elderly client from long term care facility is admitted with sepsis. The family is tearful and does not understand how their family member got so sick from a bed sore.
 
  The nurse teaches the family which of the following to help in the care of this client? 1. Assist the client at mealtimes to obtain optimal nourishment
   2. Assist the client to the bathroom so there is not a fall
   3. Alert the staff when the IV runs dry
   4. Help the nurse with dressing changes

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Answer to Question 1

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.

Answer to Question 2

1. Assist the client at mealtimes to obtain optimal nourishment

Rationale:
Poor nutritional status and a slow functioning immune system contribute to the risk for sepsis in the older client. The family can help by assisting and encouraging the client to take in the proper nourishment needed. Assisting the client to the bathroom should be done by the staff who are responsible for client safety. The family is not responsible for IV or dressing changes.