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 ["A","B","D","E"]

Explanation

Choice A Reason:

Sexual intercourse is correct. Stimulation of the genitalia or other areas below the level of injury can trigger autonomic dysreflexia in individuals with spinal cord injuries.

Choice B Reason:

Tight clothing is correct. Any form of tight or restrictive clothing, including belts or waistbands, can stimulate the body below the level of injury and trigger autonomic dysreflexia.

Choice C Reason:

Nausea is incorrect. While nausea itself is not a common trigger for autonomic dysreflexia, it may occur as a result of the condition. Autonomic dysreflexia can cause a variety of symptoms, including nausea, due to the sudden increase in blood pressure.

Choice D Reason:

Surgery below the level of injury is correct. Surgical procedures performed below the level of the spinal cord injury can lead to stimulation of the body below the injury site, triggering autonomic dysreflexia.

Choice E Reason:

Urinary tract infections (UTIs) is correct. Infections of the urinary tract, especially those involving the bladder or urethra, can stimulate the body below the level of injury, leading to autonomic dysreflexia.

A. Pleural cavity decompression via needle aspiration B. Focused assessment with sonography in trauma (FAST) C. Chest x-ray D. Thoracentesis E. Ultrasound

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

Explanation

Choice A Reason:

Pleural cavity decompression via needle aspiration is inappropriate. Pleural cavity decompression via needle aspiration may be indicated in cases of tension pneumothorax, a potentially life-threatening condition in which air accumulates in the pleural space and compresses the lung. While it is an intervention rather than a diagnostic tool, it may be performed emergently if tension pneumothorax is suspected based on clinical findings.

Choice B Reason:

Focused assessment with sonography in trauma (FAST) is appropriate. FAST is a bedside ultrasound examination commonly used in trauma settings to rapidly assess for the presence of free fluid in the pericardial, pleural, and peritoneal spaces. It can help identify hemopericardium, hemothorax, or intra-abdominal hemorrhage, which may be indicative of thoracic injury.

Choice C Reason:

Chest x-ray is appropriate. Chest x-ray is a commonly used imaging modality for evaluating thoracic injuries. It can help visualize abnormalities such as rib fractures, pneumothorax, hemothorax, pulmonary contusions, or other traumatic injuries to the chest.

Choice D Reason:

Thoracentesis is appropriate. Thoracentesis is a procedure used to sample fluid from the pleural space for diagnostic or therapeutic purposes. It may be indicated if there is a suspicion of pleural effusion or if fluid accumulation is seen on imaging studies such as chest x-ray or ultrasound.

Choice E Reason:

Ultrasound is appropriate. Ultrasound can be used to evaluate various aspects of thoracic injuries, including the presence of pneumothorax, hemothorax, or pleural effusion. It is often used as part of the FAST examination but can also be performed separately for more detailed assessment.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at the first thoracic level. Which of the following should the nurse recognize can trigger autonomic dysreflexia? (Select All that Apply.)

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

Explanation

A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.) (Select All that Apply.)

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

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.)