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. Normal sinus rhythm (NSR) at 84 beats/minute. The goal of cardioversion for atrial fibrillation (AFib) is to restore a normal sinus rhythm (NSR). NSR indicates that the atria and ventricles are depolarizing in a coordinated manner, reducing the risk of thromboembolism, stroke, and hemodynamic instability. A heart rate of 84 beats/minute is within the normal range, confirming the success of the procedure.
B. Regular rhythm with consistent pacemaker capture. Cardioversion is used to restore normal rhythm in AFib, not to manage pacemaker function. A pacemaker is not part of standard AFib cardioversion unless the client has underlying conduction issues requiring pacing.
C. Return of elevated ST segment to the baseline. ST elevation suggests acute myocardial infarction (MI), which is unrelated to atrial fibrillation or cardioversion. Cardioversion does not treat ST elevation or myocardial ischemia, making this an incorrect indicator of success.
D. Increased frequency of QRS complexes. An increase in QRS frequency suggests tachycardia, which would indicate treatment failure rather than success. The goal of cardioversion is to restore a normal, controlled heart rate and rhythm, not to increase the number of ventricular contractions.

A. Low partial pressure of oxygen (PaO2) B. Low lactic acid C. Low pH D. Low bicarbonate (HCO3-) E. High partial pressure of carbon dioxide (PaCO2)

Correct Answer is ["C","D"]

Explanation

A. Low PaO2. Clients with DKA do not typically have significant hypoxemia unless there is concurrent respiratory compromise. The primary issue in DKA is metabolic acidosis rather than oxygenation.
B. Low lactic acid. Lactic acidosis is not a hallmark of DKA. Instead, DKA is characterized by ketone production from fatty acid metabolism. Elevated lactic acid is more common in conditions like sepsis or tissue hypoxia.
C. Low pH. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to the accumulation of ketone bodies, leading to a pH below 7.35. The absence of insulin results in unregulated lipolysis and ketogenesis, significantly lowering blood pH.
D. Low bicarbonate (HCO3-). In metabolic acidosis, bicarbonate acts as a buffer and gets depleted while neutralizing excess acids. Clients with DKA typically have a bicarbonate level below 18 mEq/L (18 mmol/L), confirming metabolic acidosis.
E. High PaCO2. In metabolic acidosis, respiratory compensation leads to hyperventilation (Kussmaul respirations), causing PaCO2 to decrease as the body attempts to blow off excess CO2 to normalize pH.

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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?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is ["C","D"]

Explanation

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