# Stage 1 — Recognize cues. The emergency department nurse completes the initial assessment. Highlight the findings that require immediate follow-up. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617246&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question Stage 1 — Recognize cues. The emergency department nurse completes the initial assessment. Highlight the findings that require immediate follow-up. A 58-year-old adult with type 2 diabetes and recurrent kidney stones arrives with 2 days of fever, right flank pain, dysuria, and vomiting. The spouse states the client worked a full day 2 days ago and managed all of their own medications. Creatinine last year was 0.9 mg/dL. Current findings: temperature 39.4 C (102.9 F); right flank pain rated 7/10; burning and frequency with urination; vomited twice since midnight. HR 124/min, RR 28/min, BP 82/48 mm Hg (MAP 59), SpO2 94% on room air. Lungs clear in all fields. The skin is warm; knees mottled, capillary refill 4 seconds. 15 mL of urine in the past 2 hours. Abdomen soft with active bowel sounds. The client cannot name the month or the hospital and answers slowly. Numbness of both feet since 2019. Capillary glucose 186 mg/dL. Lactate, cultures, and imaging are pending. ## Explanation The MAP of 59, mottling with delayed refill, oliguria, and new disorientation (the client was fully independent 2 days ago) show that perfusion to the circulation, kidneys, and brain is failing and require immediate action. Dysuria and vomiting fit the urinary infection but do not by themselves indicate shock, clear lungs and a soft abdomen with bowel sounds point away from pneumonia or an abdominal source, and chronic neuropathy and moderate stress hyperglycemia are not driving the immediate danger. ## In-depth explanation Quick answer Select BP 82/48 (MAP 59), mottled knees with capillary refill 4 seconds, 15 mL of urine in 2 hours, and inability to name the month or hospital. Why this is correct These four findings show organ hypoperfusion: arterial pressure below the MAP 65 target, peripheral mottling with slow refill despite warm central skin, kidney hypoperfusion with urine output far below 0.5 mL/kg/hr, and acute encephalopathy in a client who was working and self-managing medications 2 days earlier. Together they move the picture from urinary infection to possible septic shock. Easy analogy or mental picture The infection findings tell you where the fire started; the perfusion findings tell you the house is already losing power in several rooms. Memory hook Source cues say where; perfusion cues say how bad. Act first on how bad. NCLEX decision rule In suspected infection, prioritize findings of organ dysfunction and hypoperfusion (MAP, mentation, urine output, skin perfusion) over findings that only localize the source. Why the other choices are wrong Dysuria with frequency and vomiting are tempting because they are clearly abnormal, but they describe the urinary source and would be expected even in uncomplicated pyelonephritis. Clear lungs and a soft abdomen with active bowel sounds matter because they argue against pneumonia or an intra-abdominal source, but they are reassuring, not findings to act on. Glucose 186 mg/dL is common stress hyperglycemia in a client with diabetes and does not explain the shock. Foot numbness since 2019 is chronic neuropathy documented before this illness. References 1Society of Critical Care Medicine: Surviving Sepsis Campaign guidelinesInitial MAP target of 65 mm Hg and early recognition of hypoperfusion in sepsis and septic shock 2CDC: SepsisSigns of sepsis include confusion, low blood pressure, clammy or mottled skin, and decreased urination ## Clinical scenario Case update An adult with diabetes and prior kidney stones presents with fever, flank pain, and urinary symptoms and is now hypotensive and confused. ## Key concepts - **Mean arterial pressure** — The average arterial pressure during one cardiac cycle; values below 65 mm Hg threaten organ perfusion in sepsis. - **Skin mottling** — A patchy purplish discoloration, often first seen over the knees, that reflects poor microcirculatory perfusion. - **Oliguria** — Urine output below about 0.5 mL/kg/hr, an early marker of kidney hypoperfusion. ## Related questions - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. 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