A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Spasticity of all four extremities

Hyperreflexia along with spastic extremities

Absence of reflexes along with flaccid extremities

Positive Babinski reflex along with spastic extremities

Answer and Explanation

The Correct Answer is C

A. Spasticity of all four extremities: Spasticity is characteristic of the upper motor neuron phase after spinal shock resolves. During spinal shock, reflexes are temporarily lost, and muscles are flaccid, making spasticity an inaccurate finding at this stage.

B. Hyperreflexia along with spastic extremities: Hyperreflexia and spasticity develop after spinal shock ends as reflex activity returns. Observing these signs during spinal shock would be inconsistent with the expected acute-phase physiology.

C. Absence of reflexes along with flaccid extremities: Spinal shock causes a temporary loss of all neurological activity below the level of injury, resulting in flaccid paralysis, loss of reflexes, and hypotonia. This presentation is typical in the initial phase following an acute spinal cord injury, such as a T2 lesion.

D. Positive Babinski reflex along with spastic extremities: A positive Babinski sign and spasticity indicate upper motor neuron involvement after spinal shock has resolved. During the acute spinal shock phase, reflexes are absent, so this finding would not be expected.

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Correct Answer is B

Explanation

A. distended neck veins, widening pulse pressure, drop in cardiac output: Cardiac tamponade typically causes narrowing, not widening, of the pulse pressure due to equalization of diastolic pressures and reduced stroke volume.

B. drop in cardiac output, narrowing pulse pressure, jugular vein distension: These are classic signs of cardiac tamponade. Accumulation of fluid in the pericardial sac restricts ventricular filling, decreasing stroke volume and cardiac output, narrowing pulse pressure, and causing venous congestion visible as jugular vein distension.

C. bradycardia, hypotension, narrowing pulse pressure: Hypotension and narrowed pulse pressure are relevant, but bradycardia is not a typical early sign; tachycardia is more common as a compensatory response to reduced cardiac output.

D. hypotension, diminished breath sounds, jugular vein distention: Hypotension and jugular vein distension occur, but diminished breath sounds are more associated with pleural effusion or pneumothorax, not cardiac tamponade.

A. Administration of a calcium channel blocker B. Insertion of an implantable cardioverter defibrillator (ICD) C. Administration of a beta-blocker D. Insertion of an implantable pacemaker

Correct Answer is B

Explanation

A. Administration of a calcium channel blocker: Calcium channel blockers are primarily used to manage hypertension, angina, or certain arrhythmias. They do not prevent sudden cardiac death in clients with severe left ventricular dysfunction and have not been shown to improve survival in this population.

B. Insertion of an implantable cardioverter defibrillator (ICD): An ICD continuously monitors the heart rhythm and delivers an electrical shock to terminate life-threatening ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. This intervention significantly reduces the risk of sudden cardiac death and improve long-term survival in clients with severe left ventricular dysfunction.

C. Administration of a beta-blocker: Beta-blockers improve survival in heart failure and reduce the incidence of arrhythmias, but they do not provide immediate protection against sudden cardiac death in high-risk patients as effectively as an ICD.

D. Insertion of an implantable pacemaker: A pacemaker regulates bradyarrhythmias and maintains adequate heart rate but does not terminate life-threatening ventricular tachyarrhythmias. It does not have the same protective effect against sudden cardiac death as an ICD.

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A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

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