A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

Respirations are shallow, labored, and 14 breaths/minute.

Has flaccid upper and lower extremities.

Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute.

Is unable to feel sensation in the arms and hands.

Answer and Explanation

The Correct Answer is A

A. Respirations are shallow, labored, and 14 breaths/minute. A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.
B. Has flaccid upper and lower extremities. Flaccid paralysis is an expected finding immediately after a high spinal cord injury due to spinal shock. While this condition requires ongoing monitoring, it is not an immediate life-threatening emergency like respiratory distress.
C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. These vital signs are within normal limits and do not indicate hemodynamic instability. Neurogenic shock, which can occur with high spinal injuries, typically presents with hypotension and bradycardia, but this client’s current BP and HR are stable.
D. Is unable to feel sensation in the arms and hands. Loss of sensation is expected with a cervical spinal cord injury due to nerve pathway disruption. While this finding is significant, it does not require immediate intervention compared to respiratory distress, which is the most urgent priority.

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Correct Answer is A

Explanation

A. Muffled heart tones. Muffled heart tones in a client with blunt chest trauma are a key sign of cardiac tamponade, a life-threatening emergency where blood or fluid accumulates in the pericardial sac, preventing proper cardiac filling. This condition is part of Beck's triad (muffled heart tones, hypotension, and jugular vein distention) and requires immediate intervention, such as pericardiocentesis, to relieve pressure on the heart.
B. Bilateral sonorous wheezes. While wheezing indicates airway obstruction or bronchospasm, it is not as immediately life-threatening as cardiac tamponade. The nurse should continue monitoring and consider interventions like bronchodilators, but the priority is addressing muffled heart tones.
C. Widening pulse pressure. A widening pulse pressure (increased difference between systolic and diastolic BP) is typically associated with increased intracranial pressure (ICP) rather than blunt chest trauma. In chest trauma, a narrowing pulse pressure (e.g., in hypovolemic or obstructive shock) would be a greater concern.
D. Decreased urinary output. Reduced urine output may indicate shock or poor perfusion, but it is not the most urgent finding compared to muffled heart tones, which suggest impending cardiovascular collapse. While decreased urinary output should be addressed, cardiac tamponade takes priority due to the immediate risk of death.

A. Measure the client's abdominal girth. B. Monitor the client's recent hemoglobin levels. C. Prepare for nasogastric tube (NGT) insertion. D. Notify the healthcare provider (HCP) of the client's status.

Correct Answer is D

Explanation

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

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