The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the health care provider?

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Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (eg, pressure injury), that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-related decreases in the immune and inflammatory response (ie, immunosenescence). Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead, nurses must observe for and immediately report atypical indicators of infection (eg, altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality (Option D). (Option A) Chronic use of central nervous system depressants (eg, alcohol) causes a reflexive increase in catecholamine production (eg, epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine production is no longer inhibited. (Option B) Clients with stable angina (ie, chest and jaw pain relieved with sublingual nitroglycerin) often experience orthostatic hypotension, an adverse effect of nitrate drugs. (Option C) Clients with chronic kidney disease (CKD) commonly experience nausea and pruritus due to buildup of nitrogenous wastes in the blood (ie, azotemia). Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by the nurse after management of infection and sepsis. Educational objective: Immunosenescence is an age-related decrease in the immune and inflammatory responses that increases older adult clients' risk of infection and sepsis and causes atypical signs of infection (eg, hypothermia, altered mental status, leukopenia). Atypical signs of infection should be immediately reported to increase the client's chance of survival.

The Nurse Is Performing Beginning of Shift Assessments on 4