# Stage 3 — Prioritize hypotheses. A 78-year-old long-term-care resident with dementia (baseline: conversational and follows simple directions) has an indwelling urinary catheter placed 30 days ago and recurrent UTIs. Today she is difficult to arouse and cannot hold attention. BP is 86/52, HR 118, RR 24, temperature 38.9°C (102°F) with shaking chills, and SpO2 94% without dyspnea. Mottling is present over both knees with capillary refill of 3 seconds, and there is new suprapubic tenderness. Urine in the drainage bag is cloudy, unchanged for weeks. Fingerstick glucose is 164 mg/dL, and there is no facial droop or limb weakness. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617386&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

Stage 3 — Prioritize hypotheses. A 78-year-old long-term-care resident with dementia (baseline: conversational and follows simple directions) has an indwelling urinary catheter placed 30 days ago and recurrent UTIs. Today she is difficult to arouse and cannot hold attention. BP is 86/52, HR 118, RR 24, temperature 38.9°C (102°F) with shaking chills, and SpO2 94% without dyspnea. Mottling is present over both knees with capillary refill of 3 seconds, and there is new suprapubic tenderness. Urine in the drainage bag is cloudy, unchanged for weeks. Fingerstick glucose is 164 mg/dL, and there is no facial droop or limb weakness. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Acute ischemic stroke
Sepsis with hypoperfusion from a urinary source
Catheter-associated asymptomatic bacteriuria
Progression of chronic dementia

Actions to take

Select 2
Prepare the client for CT and thrombolytic evaluation
Collect a urine specimen from the drainage bag
Obtain blood cultures and give prescribed antibiotics
Send a urine culture and start antibiotics once it results
Give the prescribed balanced crystalloid bolus

Parameters to monitor

Select 2
NIH Stroke Scale score
Serum lactate level
Urine clarity in the drainage bag
Mean arterial pressure
Mini-Mental State Examination score

## Explanation

An acute change in attention with fever, rigors, hypotension, mottling, and new suprapubic tenderness in a client with a long-term catheter indicates probable sepsis with hypoperfusion from a urinary source. Blood cultures and prescribed antibiotics should be given without delay, together with a balanced crystalloid bolus. Lactate and mean arterial pressure show whether perfusion is being restored.

## In-depth explanation

Quick answer
Sepsis with hypoperfusion from a urinary source. Obtain blood cultures and give prescribed antibiotics; give the prescribed balanced crystalloid bolus. Monitor serum lactate and mean arterial pressure.

Why this is correct
The client is acutely worse than her documented baseline and has fever with rigors, hypotension, tachycardia, and mottling, which signal infection with organ hypoperfusion. New suprapubic tenderness with a 30-day catheter identifies a likely urinary source. For possible septic shock, cultures are drawn and antimicrobials started within 1 hour, and crystalloid resuscitation begins while perfusion is reassessed.

Easy analogy or mental picture
Sepsis is a house fire that has started to cut the power: the fever is the fire (infection) and the mottled knees and confusion are the lights going out (poor perfusion). You fight the fire (antibiotics) and restore power (fluids) at the same time.

Memory hook
"New confusion + fever + low BP + catheter = sepsis until proven otherwise." Cultures, antibiotics, fluids; watch lactate and MAP.

NCLEX decision rule
When an older adult has an acute mental-status change with hypotension and fever, treat for sepsis immediately and judge progress by perfusion markers, not by the appearance of the urine.

Why the other choices are wrong
A stroke can cause acute decreased alertness, but there is no focal deficit, and fever with shock points to infection, so CT for thrombolysis and NIHSS do not address the problem. Asymptomatic bacteriuria explains cloudy urine, but this client has systemic signs, and urine appearance has not changed, so it does not track progress. Dementia progression is gradual, whereas this change is acute, so MMSE scoring is not a response measure. A drainage-bag sample is contaminated (samples come from a fresh catheter or sampling port), and waiting for urine culture results before antibiotics delays time-critical treatment.

References
1Society of Critical Care Medicine: Surviving Sepsis Campaign guidelinesFor possible septic shock give antimicrobials within 1 hour, obtain cultures first when feasible, begin crystalloid resuscitation, and trend lactate and MAP

## Clinical scenario

Case update
Screening confirms an acute change from baseline with hypotension, fever, and poor perfusion; cultures and lactate have not yet been drawn.

## Key concepts

- **Hypoperfusion** — Inadequate tissue blood flow, shown by hypotension, mottling, delayed capillary refill, altered mentation, or rising lactate.
- **Mean arterial pressure (MAP)** — The average arterial pressure driving organ perfusion; the usual initial target in septic shock is 65 mm Hg.
- **Asymptomatic bacteriuria** — Bacteria in the urine without infection symptoms, common with long-term catheters and not treated with antibiotics.

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