[Case Study 1, Screen 1.] Complete the sentence by choosing one option for each blank. The client is at highest risk for developing [Blank 1: options A-C] as evidenced by [Blank 2: options D-F].

CLIENT
63-year-old woman. Weight 70 kg.
History: type 2 diabetes (takes metformin), hypertension (takes lisinopril).
Lives with spouse; independent in all activities; baseline fully oriented.
Home blood pressure readings usually about 132/78 mm Hg.

NURSES' NOTES - 0800
Spouse reports the client has been "sleepy and confused" since last night.
Client reports burning on urination for 3 days and has been eating and
drinking very little for 2 days. Oriented to person only. Skin warm and
flushed; mucous membranes dry. Reports right flank pain, 5/10. Lungs clear
bilaterally. Capillary refill 3 seconds. Last voided a small amount of dark
urine early this morning.

VITAL SIGNS - 0800
Temperature      39.0°C (102.2°F)
Heart rate       116/min
Respiratory rate 24/min
Blood pressure   88/50 mm Hg (MAP 63 mm Hg)
SpO2             95% on room air

LABORATORY RESULTS - 0815            Result            Reference range
WBC                                  18,600/mm³        5,000-10,000/mm³
  Bands                              14%               0-5%
Lactate                              4.1 mmol/L        0.5-2.0 mmol/L
Creatinine                           1.9 mg/dL         0.5-1.1 mg/dL
  (baseline 1 month ago: 0.9 mg/dL)
BUN                                  40 mg/dL          7-20 mg/dL
Glucose (random)                     238 mg/dL         70-140 mg/dL
Sodium                               137 mEq/L         135-145 mEq/L
Potassium                            4.6 mEq/L         3.5-5.0 mEq/L
Platelets                            172,000/mm³       150,000-400,000/mm³
Urinalysis: cloudy; nitrite positive; leukocyte esterase positive;
            WBC more than 50/hpf

ABlank 1: hyperosmolar hyperglycemic state
BBlank 1: septic shock
CBlank 1: acute respiratory distress syndrome
DBlank 2: a respiratory rate of 24/min with an SpO2 of 95% on room air
EBlank 2: a blood glucose of 238 mg/dL with dry mucous membranes
FBlank 2: a blood pressure of 88/50 mm Hg with a lactate of 4.1 mmol/L

Show answer and explanations

Answer

Blank 1 → B; Blank 2 → F

A: The glucose level and infected hypotensive presentation do not support HHS as the best explanation. B: Infection with hypotension (MAP 63 mm Hg), lactate 4.1 mmol/L, and new organ dysfunction places the client at highest risk for progression to septic shock. C: Current oxygenation and lung findings do not establish ARDS. D: This respiratory finding alone does not establish circulatory shock. E: Moderate hyperglycemia and dryness are less specific than the hypotension-lactate pair. F: Hypotension with elevated lactate supports the urgent perfusion concern.

A

The glucose level and infected hypotensive presentation do not support HHS as the best explanation.

B

Infection with hypotension (MAP 63 mm Hg), lactate 4.1 mmol/L, and new organ dysfunction places the client at highest risk for progression to septic shock.

C

Current oxygenation and lung findings do not establish ARDS.

D

This respiratory finding alone does not establish circulatory shock.

E

Moderate hyperglycemia and dryness are less specific than the hypotension-lactate pair.

F

Hypotension with elevated lactate supports the urgent perfusion concern.