# Stage 1 — Recognize cues. A 78-year-old client is brought to the emergency department from a long-term-care facility. Review the admission note. Highlight the findings that require immediate follow-up. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617310&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question Stage 1 — Recognize cues. A 78-year-old client is brought to the emergency department from a long-term-care facility. Review the admission note. Highlight the findings that require immediate follow-up. A 78-year-old long-term-care resident with dementia is brought in by EMS. Her documented baseline is alert to person, conversational, and able to follow simple directions. She has an indwelling Foley for chronic urinary retention placed 30 days ago, recurrent UTIs over the past year, type 2 diabetes, and hypertension controlled on her usual regimen. Today she is difficult to arouse and cannot hold attention, although she is oriented to person only, as usual. Vital signs: BP 86/52, HR 118, RR 24, T 38.9 C with shaking chills, and SpO2 94 percent without dyspnea. There is mottled skin over both knees with capillary refill of 3 seconds, and there is new tenderness above the pubic bone. The drainage bag holds cloudy urine, unchanged for weeks per staff. EMS reported a fingerstick glucose of 164 mg/dL. There is no facial droop or limb weakness. ## Explanation Being hard to arouse and unable to hold attention is an acute change from her documented conversational baseline, whereas orientation to person only is her usual dementia state. Hypotension with tachycardia and tachypnea, fever with rigors, knee mottling, and new suprapubic tenderness require immediate follow-up because they signal systemic infection, poor perfusion, and a possible urinary source. Cloudy drainage-bag urine that staff report has looked the same for weeks is common with a long-term catheter and does not establish infection, and a glucose of 164 mg/dL is modest for a client with type 2 diabetes. ## In-depth explanation Quick answer Highlight the reduced arousal and inattention, BP 86/52 with HR 118 and RR 24, T 38.9 C with rigors, mottled knees, and new suprapubic tenderness. Why this is correct Her baseline is conversational and able to follow directions, so difficulty arousing and inability to sustain attention is a new acute change that suggests organ dysfunction. Hypotension, tachycardia, tachypnea, and mottling show impaired perfusion, fever with shaking chills suggests bacteremia, and new suprapubic tenderness localizes a possible urinary source. These cues warrant a sepsis response before laboratory results return. Easy analogy or mental picture Dementia is her usual weather; today's storm is the part that changed. Disorientation to place and time is the climate, but not waking up properly is the storm warning. Memory hook In dementia, compare with her baseline, not with a healthy adult: same orientation is old, less alertness is new. NCLEX decision rule In clients with chronic cognitive impairment or chronic devices, treat changes from the documented baseline as cues and treat long-standing findings as context. A single nonspecific finding, such as cloudy bag urine, is not enough to act on without systemic signs. Why the other choices are wrong Orientation to person only looks alarming but is her documented baseline. Cloudy bag urine is unchanged for weeks according to facility staff, is frequent with long-term catheters, and does not by itself establish CAUTI; the new suprapubic tenderness is the more meaningful source cue. A fingerstick glucose of 164 mg/dL is mildly elevated for someone with type 2 diabetes and does not explain the hypotension or drowsiness. SpO2 94 percent without dyspnea is acceptable for her age. No facial droop or limb weakness argues against stroke, and recurrent UTIs and controlled hypertension are background history. References 1Society of Critical Care Medicine: Surviving Sepsis CampaignAcute organ dysfunction, hypotension, and signs of hypoperfusion in suspected infection require urgent sepsis evaluation 2CDC: About SepsisConfusion, fever or shivering, and signs of poor perfusion can indicate sepsis; older adults are at higher risk 3CDC Guideline for Prevention of Catheter-Associated Urinary Tract InfectionsBacteriuria is common with long-term catheters; urine is sampled from the port, not the drainage bag ## Clinical scenario Scenario (Stage 1 — Recognize cues) A long-term-care resident with dementia and a 30-day indwelling catheter is brought in because she is unusually drowsy and febrile. Clinical judgment target Compare mental status with the documented dementia baseline and separate new systemic and perfusion cues from chronic, expected, or nonspecific findings. ## Key concepts - **Sepsis-induced hypoperfusion** — Inadequate tissue perfusion from sepsis, shown by hypotension, mottling, delayed capillary refill, or elevated lactate. - **Acute change in mental status** — A new decline in arousal or attention compared with the client's documented baseline, a common early sign of sepsis in older adults. - **Catheter-associated bacteriuria** — Bacteria in urine from a long-term catheter that is common and does not by itself indicate symptomatic infection. ## 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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