A 72-year-old client is admitted from a skilled nursing facility with altered mental status and a productive cough. The nurse performs an assessment and documents the following findings: Temperature 101.8°F (38.8°C), heart rate 94 beats/min, respiratory rate 24 breaths/min, blood pressure 118/72 mm Hg, and WBC count 14,200/mm3. Based on the SIRS criteria, which findings indicate this client meets criteria for systemic inflammatory response syndrome? Select all that apply.

A. This is above 100.4°F, indicating fever and satisfying the SIRS criterion for abnormal temperature. Fever occurs as a response to cytokine release during systemic inflammation or infection. B. Heart rate greater than 90 beats/min meets the SIRS criterion. Tachycardia occurs in early SIRS as a compensatory response to maintain cardiac output in the presence of systemic inflammation or relative hypoperfusion. C. This exceeds 20 breaths/min and meets the SIRS criterion for tachypnea. Increased respiratory rate is an early compensatory mechanism to improve oxygen delivery to tissues and eliminate CO₂ during systemic inflammation. D. This is within normal limits. Blood pressure is not part of SIRS criteria, although hypotension can develop later in sepsis progression. A normal BP does not rule out SIRS. E. Elevated WBC count indicates leukocytosis, meeting the SIRS criterion. This reflects the body’s immune response to infection or systemic inflammation.