A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Increased oxygen saturation.

Urine output less than 30 mL/hr.

Decreased level of consciousness.

Heart rate of 34 beats/min.

Answer and Explanation

Correct Answer : B,D

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

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Correct Answer is A

Explanation

Choice A reason:

The extent of impairment following a spinal cord injury cannot be determined until any secondary injury to the cord has resolved. Secondary injury, such as inflammation and swelling, can worsen the initial damage and impact the long-term prognosis.

Choice B reason:

An MRI can reveal the extent of cord damage but does not provide a complete picture of the potential functional outcomes. The full extent of impairment cannot be determined solely by imaging.

Choice C reason:

Stating that the patient will have normal function when spinal shock resolves and the reflex arc returns is misleading and overly optimistic. Not all patients will regain normal function after a spinal cord injury, and outcomes vary.

Choice D reason:

While rehabilitation plays a crucial role in recovery, stating that it will be years before impairment can be determined is not entirely accurate. Functional outcomes can often be assessed sooner as the initial recovery phase progresses.

A. Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain. B. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing. C. Morphine sulfate 4 mg IV now for the client experiencing incisional pain. D. One unit packed red blood cells STAT for the client with hemoglobin of 9.5 g/dL.

Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

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A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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