A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.)
(Select All that Apply.)

Temperature 36.3° C (97.4° F)

Respirations 12/min

Blood pressure 184/88 mm Hg

Heart rate 54/min

Calcium level 7.0 mg/dL

Answer and Explanation

Correct Answer : A,D

Choice A Reason:

Temperature 36.3°C (97.4°F) is correct. Hypothermia is a characteristic finding in neurogenic shock due to the loss of sympathetic control over temperature regulation and peripheral vasodilation. This can lead to heat loss from the skin surface and a decrease in core body temperature.

Choice B Reason:

Respirations 12/min is incorrect. Respiratory rate is usually not significantly affected in neurogenic shock. However, individuals with high cervical or upper thoracic spinal cord injuries may experience respiratory compromise due to paralysis of respiratory muscles, but this is not a typical feature of neurogenic shock.

Choice C Reason:

Incorrect: Neurogenic shock typically results in hypotension (low blood pressure) due to vasodilation. The given blood pressure reading is elevated, which is not consistent with neurogenic shock.

Choice D Reason:

Heart rate 54/min is correct. Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity resulting from the loss of sympathetic tone. The heart rate may be slow and may decrease further over time.

Choice E Reason:

Calcium level 7.0 mg/dL is incorrect, Calcium levels are not directly related to neurogenic shock. Neurogenic shock primarily involves the loss of sympathetic tone and the resulting hemodynamic changes, rather than alterations in calcium metabolism.

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Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:

Loss of teeth is not typically considered a direct factor contributing to obstructive sleep apnea. While the presence of teeth may play a role in maintaining the structure of the oral cavity, it is not a primary risk factor for OSA.

Choice B Reason:

Stroke is correct. Individuals who have had a stroke are at increased risk of developing obstructive sleep apnea. Stroke can cause damage to areas of the brain involved in controlling breathing and upper airway function, leading to disruptions in respiratory control during sleep.

Choice C Reason:

Sleepiness is a symptom commonly associated with obstructive sleep apnea rather than a direct contributing factor. Excessive daytime sleepiness is a consequence of disrupted sleep patterns and recurrent episodes of breathing cessation during the night, which are characteristic features of obstructive sleep apnea.

Choice D Reason:

Fatty deposits is correct. Excessive fatty deposits, particularly around the neck and throat, can contribute to the narrowing and collapse of the upper airway during sleep, increasing the risk of obstructive sleep apnea. Obesity is a significant risk factor for OSA due to the accumulation of fat deposits in the upper airway tissues.

Choice E Reason:

Muscle dysfunction is correct. Muscle dysfunction, particularly of the muscles surrounding the upper airway, can impair the ability of these muscles to keep the airway open during sleep. Weakness or dysfunction of these muscles can lead to increased collapsibility of the upper airway, contributing to obstructive sleep apnea.

A. Decreased visual acuity B. Motor vehicle crashes C. Polypharmacy D. Weakness E. Chronic hypertension F. Previous military experience

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Decreased visual acuity is correct. Yes, decreased visual acuity, including issues such as poor depth perception, reduced peripheral vision, and difficulty with contrast sensitivity, can contribute to falls and head injuries in older adults.

Choice B Reason:

Motor vehicle crashes is incorrect. While motor vehicle crashes can cause head injuries in individuals of all ages, they are less common among older adults compared to younger age groups.

Choice C Reason:

Polypharmacy is correct. Yes, polypharmacy, which refers to the use of multiple medications concurrently, is a common risk factor for falls and head injuries in older adults. Certain medications, especially those with sedative or psychotropic effects, can increase the risk of falls and accidents.

Choice D Reason:

Weakness is correct. Yes, weakness, frailty, and decreased muscle strength are common age-related changes that can increase the risk of falls and subsequent head injuries in older adults.

Choice E Reason:

Chronic hypertension, particularly when poorly controlled, can contribute to an increased risk of falls in older adults through various mechanisms:Hypertension medications or the condition itself can lead to orthostatic hypotension. This can cause dizziness or lightheadedness, increasing the risk of falls.Chronic hypertension is a major risk factor for cerebrovascular disease, including strokes. These events can lead to neurological deficits such as weakness, numbness, or impaired balance, predisposing individuals to falls.

Choice F Reason:

Previous military experience is incorrect. While previous military experience may contribute to certain health conditions or injuries in older adults, it is not a common reason for head injuries specifically related to falls or accidents in this population.

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A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.) (Select All that Apply.)

Nursing Test Bank

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Correct Answer is ["B","D","E"]

Explanation

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Explanation

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A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.)
(Select All that Apply.)