A client has sustained a T4-T5 injury and the nurse suspects he is in neurogenic shock. Which of the following manifestations are consistent with neurogenic shock? Select All that Apply
A hypertension
B rapidly elevating temperature
C bradycardia
D fixed and dilated pupils
E hypotension
Correct Answer : C,E
Choice A Rationale: Hypertension is not a sign of neurogenic shock, but rather of autonomic dysreflexia, a life-threatening condition that can occur in patients with spinal cord injury above T6.
Choice B Rationale: Rapidly elevating temperature is also a sign of autonomic dysreflexia, not neurogenic shock. Neurogenic shock can cause hypothermia due to impaired thermoregulation.
Choice C Rationale: Bradycardia is a sign of neurogenic shock due to the loss of sympathetic stimulation to the heart, which normally increases the heart rate and contractility.
Choice D Rationale: Fixed and dilated pupils are a sign of brain death, not neurogenic shock. Neurogenic shock can cause miosis (constriction of the pupils) due to unopposed parasympathetic stimulation.
Choice E Rationale: Hypotension is a sign of neurogenic shock due to the vasodilation and decreased venous return caused by the loss of sympathetic tone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: A person who makes up stories when he is unable to remember actual events is confabulating. This can be seen as a way of filling in the blanks in their memory with plausible details that may or may not have happened. For example, a person with dementia may confabulate that they had lunch with a friend yesterday, when in fact they did not see anyone.
Choice B Rationale: reminiscing about the past, which is a normal and healthy way of recalling one's life experiences and sharing them with others.
Choice C Rationale: displaying compulsive and ritualistic behaviors, which are repetitive actions that a person feels compelled to perform, often as a way of reducing anxiety or distress.
Choice D Rationale: refusing to leave home to see a provider, which is a sign of agoraphobia, a fear of being in situations where escape might be difficult or embarrassing.
Correct Answer is ["A","C"]
Explanation
Choice A Rationale: Asking the spouse what she knows about dementia care options is a good starting point to assess her knowledge and provide information and resources, and empowering her to make informed decisions.
Choice B Rationale: Suggesting placement into a long-term care facility should not be the first option but can be explored if necessary, based on the client's condition and the caregiver's needs.
Choice C Rationale: Teaching the spouse about adult day care as a possible respite is a way of offering support and relief for the caregiver, who may experience stress and burnout from the constant demands of caring for a patient with AD.
Choice D Rationale: Suggesting that the spouse consult with the physician for antianxiety drugs is not helpful, as it may imply that the spouse's feelings are abnormal or that she needs medication to cope.
Choice E Rationale: Offering ideas for ways to distract or redirect the patient is not relevant to the spouse's needs, as it does not address her exhaustion and worry.
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