A client who has sustained a spinal cord injury above the level of T6 presents with bradycardia, hypotension, and warm, flushed skin. Which of the following findings is most indicative of neurogenic shock rather than spinal shock?

Hypothermia

Warm, flushed skin

Increased heart rate

Persistent hypertension

Answer and Explanation

The Correct Answer is B

Neurogenic shock is a distributive type of shock that occurs after spinal cord injury, most commonly with injuries above the level of T6. It results from loss of sympathetic nervous system control, causing widespread vasodilation, bradycardia, and hypotension. Spinal shock, in contrast, refers to the temporary loss of reflexes, motor function, and sensation below the level of injury rather than a hemodynamic problem. Distinguishing between these two conditions is important because neurogenic shock requires urgent cardiovascular support.

Rationale:
A. Hypothermia may occur in neurogenic shock due to loss of temperature regulation and peripheral vasodilation, but it is not the most distinctive sign used to differentiate it from spinal shock. Many critically ill clients can develop temperature instability from other causes as well. The more specific hallmark is the presence of warm, flushed skin with hypotension and bradycardia.

B. Warm, flushed skin is most indicative of neurogenic shock because loss of sympathetic tone causes peripheral vasodilation and blood pooling in the extremities. This leads to decreased systemic vascular resistance, hypotension, and skin that feels warm and dry rather than cool and clammy. This finding helps distinguish neurogenic shock from hypovolemic shock and from spinal shock, which is primarily neurologic rather than circulatory.

C. Increased heart rate is not expected in neurogenic shock because the loss of sympathetic stimulation causes bradycardia rather than tachycardia. Most other forms of shock produce compensatory tachycardia, but neurogenic shock is unique in presenting with a slow heart rate. Therefore, increased heart rate would suggest another cause of instability rather than neurogenic shock.

D. Persistent hypertension is inconsistent with neurogenic shock because widespread vasodilation leads to hypotension, not elevated blood pressure. The client loses vascular tone and cannot maintain adequate perfusion pressure. Hypertension may occur later with autonomic dysreflexia, but it is not the characteristic presentation of acute neurogenic shock.

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Correct Answer is A

Explanation

A Sengstaken-Blakemore tube is used as an emergency measure to control life-threatening bleeding from esophageal varices by applying direct pressure to bleeding sites using inflated gastric and esophageal balloons. This intervention carries significant risks, including airway obstruction, aspiration, and esophageal rupture. Because the tube is placed near the airway and upper gastrointestinal tract, maintaining airway patency and preventing aspiration are the highest priorities during care.

Rationale:
A. Assessing the client for respiratory distress and signs of aspiration is the most critical nursing action because inflation of the balloons can compress the airway and increase the risk of aspiration of blood or gastric contents. Any signs of dyspnea, hypoxia, or coughing may indicate airway compromise, which requires immediate intervention to prevent respiratory failure.

B. Confirming the lumens of the tube are properly labeled is important for correct management of the gastric and esophageal ports but is not the most urgent priority. While proper labeling helps ensure correct inflation and drainage, it does not address immediate life-threatening complications such as airway obstruction or aspiration.

C. Monitoring the gastric balloon pressure every hour is necessary to ensure the balloon is providing adequate tamponade without causing tissue damage or rupture. However, this is a secondary monitoring task compared to airway safety. Overinflation risks esophageal necrosis, but airway protection remains the primary concern.

D. Ensuring the client is in a supine position for comfort is incorrect because the supine position increases the risk of aspiration in a client with active upper gastrointestinal bleeding. The client should typically be positioned with the head elevated or in a lateral position to reduce aspiration risk and support airway protection.

A. Maintain proper cuff inflation pressure on the endotracheal tube to ensure airway patency. B. Position the client in a supine position to facilitate breathing. C. Administer high-flow nasal oxygen to increase oxygenation. D. Increase the tidal volume on the ventilator to enhance lung expansion.

Correct Answer is A

Explanation

Flail chest occurs when multiple consecutive ribs are fractured in more than one place, creating a free-floating segment of the chest wall that moves paradoxically during respiration. This injury significantly impairs ventilation and often requires mechanical ventilation for respiratory support and stabilization. Ensuring a secure airway and preventing aspiration are critical priorities in clients with endotracheal intubation. Proper management of the airway cuff is essential to maintain ventilation effectiveness and protect the lower respiratory tract.

Rationale:
A. Maintaining proper cuff inflation pressure on the endotracheal tube is the priority intervention because it ensures a sealed airway, prevents air leaks, and reduces the risk of aspiration of gastric or oropharyngeal contents. Adequate cuff pressure also supports effective mechanical ventilation by ensuring that delivered tidal volumes reach the lungs without loss.

B. Positioning the client in a supine position is not appropriate because it can impair lung expansion and increase the risk of aspiration. In clients with flail chest, semi-Fowler’s position is preferred to improve diaphragmatic excursion and promote better oxygenation while reducing pressure on the chest wall.

C. Administering high-flow nasal oxygen is not the priority because the client is already mechanically ventilated. Oxygen delivery alone does not address the structural instability of the chest wall or the need for airway protection. Mechanical ventilation provides more effective respiratory support in flail chest.

D. Increasing the tidal volume on the ventilator may be used in some cases of flail chest management, but it is not the immediate priority compared to airway protection. Excessively high tidal volumes can increase the risk of barotrauma or volutrauma. Ensuring airway integrity and preventing aspiration take precedence before adjusting ventilator settings.

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A client who has sustained a spinal cord injury above the level of T6 presents with bradycardia, hypotension, and warm, flushed skin. Which of the following findings is most indicative of neurogenic shock rather than spinal shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A client with flail chest is receiving mechanical ventilation. Which of the following interventions is the priority to ensure adequate ventilation and prevent aspiration?

Correct Answer is A

Explanation

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