# Situation: A 58-year-old woman weighing 68 kg is brought to the emergency department with fever, flank pain, and new confusion. A urinary source of infection is suspected. She has no history of heart failure or kidney disease and no known drug allergies. The nurse screens her initial findings against the systemic inflammatory response syndrome (SIRS) criteria. Which finding counts as one of the SIRS criteria?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630036  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 58-year-old woman weighing 68 kg is brought to the emergency department with fever, flank pain, and new confusion. A urinary source of infection is suspected. She has no history of heart failure or kidney disease and no known drug allergies.

The nurse screens her initial findings against the systemic inflammatory response syndrome (SIRS) criteria. Which finding counts as one of the SIRS criteria?

## 보기

1. Respiratory rate of 24 breaths/min **✔ 정답**
2. White blood cell count of 11,000/µL
3. Systolic blood pressure of 88 mmHg
4. Temperature of 37.9 °C

**정답: 1**

## 해설

The SIRS criteria are temperature above 38 °C or below 36 °C, heart rate above 90/min, respiratory rate above 20/min or PaCO2 below 32 mmHg, and white blood cell count above 12,000/µL or below 4,000/µL. A respiratory rate of 24 breaths/min exceeds its cut-off. Hypotension is not a SIRS criterion; it signals shock.

## 심화 해설

Understanding SIRS Criteria in Suspected Urosepsis

The patient presents with fever, flank pain, and confusion, raising concern for a urinary source of infection with possible progression to sepsis. Screening for systemic inflammatory response syndrome (SIRS) is a foundational step in recognizing a dysregulated host response to infection. The SIRS framework identifies four clinical domains: body temperature, heart rate, respiratory rate, and white blood cell (WBC) count. Meeting 2 or more of these criteria signals a systemic inflammatory state that warrants further evaluation for sepsis and organ dysfunction [1][4].

A respiratory rate of 24 breaths/min exceeds the SIRS threshold of more than 20 breaths/min, so it counts as one positive criterion. Tachypnea in early sepsis reflects compensatory mechanisms: inflammatory mediators stimulate peripheral and central chemoreceptors, and metabolic acidosis from tissue hypoperfusion drives increased minute ventilation to blow off carbon dioxide. This makes respiratory rate a sensitive but nonspecific early warning sign.

The other options do not meet SIRS thresholds. A WBC count of 11,000/µL falls within the normal reference range and below the SIRS cutoff of greater than 12,000/µL (or less than 4,000/µL). A temperature of 37.9 °C is elevated but does not reach the SIRS criterion of above 38 °C (or below 36 °C). Systolic blood pressure of 88 mmHg is concerning for hypotension, but hypotension is not a SIRS criterion; it reflects circulatory compromise and should prompt immediate assessment for septic shock using perfusion markers such as lactate and mean arterial pressure rather than being counted as a SIRS element.

| SIRS Criterion | Threshold | This Patient | Counts? |
| --- | --- | --- | --- |
| Temperature | >38 °C or 90/min | Not provided | Cannot assess |
| Respiratory rate | >20/min or PaCO₂ 12,000/µL or

## 임상 시나리오

SIRS Screening in Suspected UrosepsisBedside criteria for early sepsis recognition
SIRS requires 2 or more of: temperature >38 °C or 90/min, respiratory rate >20/min or PaCO2 12,000/µL or

## 핵심 개념

- **SIRS** — Systemic inflammatory response syndrome; requires 2+ of: temp >38 or 90, RR >20 or PaCO2 12,000 or
- **Tachypnea** — Respiratory rate >20 breaths/min; early compensatory response in sepsis
- **Sepsis** — Life-threatening organ dysfunction caused by dysregulated host response to infection
- **Hypotension** — Low blood pressure; not a SIRS criterion but may signal shock

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