# A 7-year-old child is brought to the emergency department with a rapidly spreading skin infection. The nurse is assessing for signs of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Which assessment finding would be MOST concerning and require immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542296  
> language: ko  
> subject: Child Health

## 문제

A 7-year-old child is brought to the emergency department with a rapidly spreading skin infection. The nurse is assessing for signs of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Which assessment finding would be MOST concerning and require immediate intervention?

## 보기

1. Presence of multiple small pustules around the primary lesion
2. Complaint of moderate pain at the infection site with redness
3. Fever of 102.8°F (39.3°C) with altered mental status and hypotension **✔ 정답**
4. Purulent drainage from the center of the lesion with surrounding erythema

**정답: 3**

## 해설

Fever with altered mental status and hypotension indicates systemic sepsis requiring immediate intervention. Other findings (pustules, pain, purulent drainage) are local signs manageable with standard care.

## 심화 해설

Clinical Judgment
The core of this question is applying the 'Recognize Cues' and 'Prioritize Hypotheses' stages of the Clinical Judgment Measurement Model (CJMM). In a CA-MRSA infection, the most dangerous aspect is not the localized infection but sepsis that has spread systemically. In option 3, the fever (102.8°F), altered mental status, and hypotension are classic signs of **SIRS (Systemic Inflammatory Response Syndrome)**, strongly suggesting sepsis. This is a medical emergency requiring immediate life-sustaining interventions. The other options are merely signs of a localized infection.

Memory Tip: To remember the danger signals of CA-MRSA, think "**S**ystemic signs over **L**ocal signs." **Systemic signs (fever, hypotension, altered mental status)** always take priority over **local signs (pain, redness, abscess)**.

KR vs US
In Korea, there may be a more cautious approach to fluid administration during the initial management of a sepsis patient, but in the US NGN/NCLEX, the standard when the triad of hypotension, high fever, and altered mental status appears is to **immediately report and begin aggressive resuscitation, including fluid administration**. A 'wait-and-see' approach is never correct.

## 임상 시나리오

Clinical Practice Guide
When evaluating patients with CA-MRSA skin infections, always check for "RED FLAGS": Rapid expansion, Erythema spreading, Debilitating pain, Fever, Altered mental status/Lethargy, Generalized symptoms, Hypotension, Signs of organ dysfunction. If any of these are present, report immediately.

Caution
In SATA (Select All That Apply) questions, do not confuse "local signs of CA-MRSA infection" with "systemic signs that require immediate reporting." "Purulent drainage" or "multiple pustules" are important, but they are not the same priority as life-threatening situations like the combination of "fever + altered mental status + hypotension."

## 핵심 개념

- **Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA)** — Methicillin-resistant Staphylococcus aureus infection acquired in the community rather than in a hospital setting. It primarily causes skin and soft tissue infections and can produce the Panton-Valentine Leukocidin (PVL) toxin, leading to tissue necrosis and rapid progression.
- **Sepsis** — Life-threatening organ dysfunction caused by a dysregulated host response to infection. A condition where infection is accompanied by signs of systemic inflammatory response syndrome (SIRS) (fever, tachycardia, tachypnea, altered white blood cell count).
- **Systemic Inflammatory Response Syndrome** — Systemic inflammatory response to infectious or non-infectious injury. Diagnosed when two or more of the following are met: body temperature >38°C or 90 beats/min, respiratory rate >20 breaths/min or PaCO2 12,000/µL or 10%.
- **Hypotension** — A state where blood pressure falls below the normal range. In children, it is defined as below the 5th percentile of normal blood pressure for age, and is one of the major signs of septic shock.
- **Altered Mental Status** — Changes in normal arousal level, cognitive function, or consciousness. May present as confusion, lethargy, agitation, or decreased responsiveness, and is a sign of inadequate brain perfusion or systemic infection.

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