A nurse is assessing a client who has sepsis. Which of the following findings should the nurse report as a manifestation of possible systemic inflammatory response syndrome?

Assessment of a client with Sepsis requires early recognition of systemic inflammatory response syndrome (SIRS), which reflects dysregulated immune and inflammatory activation in response to infection or injury. SIRS criteria include abnormalities in temperature, heart rate, respiratory rate, and white blood cell count. Early identification of these changes is critical because they may progress rapidly to septic shock and multi-organ failure if not treated promptly. Rationale: A. Hypotension is a late and more severe manifestation typically associated with septic shock rather than early systemic inflammatory response syndrome. While it is an important finding in sepsis progression, it does not define SIRS itself. SIRS is identified earlier through changes such as WBC abnormalities and vital sign alterations before cardiovascular collapse occurs. B. A WBC count of 4,800/mm³ is below the normal reference range and is a key indicator of systemic inflammatory response syndrome. In sepsis, both leukocytosis and leukopenia can occur due to overwhelming immune activation and consumption of white blood cells. A decreased WBC count reflects immune system dysregulation and is a concerning sign that requires immediate reporting. C. Blood glucose of 48 mg/dL indicates hypoglycemia, which is not a defining criterion for SIRS but may occur in severe sepsis due to increased metabolic demand and impaired gluconeogenesis. However, it is not part of the diagnostic criteria for systemic inflammatory response syndrome. It still requires treatment but is not the primary marker for SIRS identification. D. Polyuria is not associated with systemic inflammatory response syndrome and is more commonly related to conditions such as diabetes insipidus, early diabetes mellitus, or fluid overload states. In sepsis, patients are more likely to experience oliguria due to poor renal perfusion rather than increased urine output. Therefore, this finding does not indicate SIRS.