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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.

Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.

Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineﬀective atrial contractions and variable ventricular response.

Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not aﬀect the heart rate or rhythm, and does not cause any symptoms.

A. Deﬂate the balloons for 5 min every 2 hr to prevent tissue necrosis. B. Keep the head of the bed ﬂat at all times to prevent the development of shock. C. Maintain constant observation while the balloons are inﬂated. D. Suction the tube every 2 hr and as needed to maintain patency. E. Suction the tube every 2 hr and as needed to maintain patency.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect. The balloons should not be deﬂated without a physician's order, as this can cause rebleeding or aspiration.

Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reﬂux.

Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.

Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is C

Explanation

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider?

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is eﬀective, the nurse should expect which of the following changes on the client’s ECG?

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?