61. When assessing a client for signs of early septic shock, a nurse should observe for:
. Cool, clammy skin.
. Warm, flushed skin.
. Decreased systolic blood pressure.
. Disseminated intravascular coagulation (DIC).
Test-Taking Tip
Know the classic difference with septic shock: fever—therefore, the client is warm and flushed.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because cool, clammy skin occurs with hypovolemia and decreased perfusion. Answer 2 is correct because there is an increase in the body temperature, and vasodilation would occur. Answer 3 is incorrect because a drop in the systolic pressure occurs with hypovolemic shock, not septic shock. Answer 4 is incorrect because DIC is a hypercoagulable condition that would be a late complication of poor perfusion.