A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)
Weakened gag reflex
Hyperthermia
Absence of bowel sounds
Paralysis
Polyuria
Hypotension
Correct Answer : A,C,D,F
Choice A: A cervical spinal cord injury can impair the function of cranial nerves, leading to a weakened gag reflex and an increased risk of aspiration.
Choice B: Patients with spinal cord injuries are more likely to experience poikilothermia (difficulty regulating body temperature), but this often results in hypothermia, not hyperthermia, due to the loss of autonomic temperature control.
Choice C: Spinal shock, which often follows a spinal cord injury, can cause decreased or absent bowel sounds due to a temporary loss of autonomic function and decreased peristalsis.
Choice D: Depending on the level and severity of the injury, paralysis can occur, affecting motor function below the injury site. A cervical spinal cord injury may lead to quadriplegia (tetraplegia).
Choice E: Clients with spinal cord injuries are more likely to experience urinary retention, rather than polyuria, due to loss of bladder control and autonomic dysfunction. A foley catheter may be needed initially, followed by intermittent catheterization.
Choice F: Neurogenic shock, a potential complication of cervical spinal cord injuries, can cause hypotension due to the loss of sympathetic nervous system control over blood vessel tone, leading to vasodilation and bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a) is incorrect because troponin is not an enzyme, but a protein. Enzymes are molecules that speed up chemical reactions in the body. Troponin does not have this function.
Choice b) is correct because troponin is a protein that binds to calcium and regulates the contraction of heart muscle fibers. When the heart muscle is injured, such as in a myocardial infarction, troponin leaks into the bloodstream and can be detected by a blood test. The higher the level of troponin, the more severe the damage to the heart.
Choice c) is incorrect because troponin does not help transport oxygen throughout the body. That function is performed by hemoglobin, which is a protein found in red blood cells.
Choice d) is incorrect because troponin is not a lipid, but a protein. Lipids are fats that are used for energy storage and cell membrane formation. Troponin does not have these roles.
Correct Answer is B
Explanation
Choice A: Ask the client to shrug his shoulders against passive resistance is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve XI, which is the accessory nerve. The accessory nerve innervates the trapezius and sternocleidomastoid muscles, which are involved in shoulder and neck movements.
Choice B: Instruct the client to look up and down without moving his head is an assessment that will give the nurse information about the function of cranial nerve III. Cranial nerve III is the oculomotor nerve, which innervates four of the six extraocular muscles that control eye movements. The oculomotor nerve also controls pupil size and lens shape. By instructing the client to look up and down without moving his head, the nurse can assess the ability of the oculomotor nerve to move the eyes vertically and adjust to different distances.
Choice C: Observe the client's ability to smile and frown is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VII, which is the facial nerve. The facial nerve innervates the muscles of facial expression, which are involved in smiling, frowning, blinking, and other facial movements.
Choice D: Have the client stand with his eyes closed and touch his nose is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VIII, which is the vestibulocochlear nerve. The vestibulocochlear nerve innervates the inner ear and is responsible for hearing and balance. By having the client stand with his eyes closed and touch his nose, the nurse can assess the ability of the vestibulocochlear nerve to maintain equilibrium and coordination.
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