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.)

A.Osmotic edema refers to fluid shifts due to changes in osmotic gradients (as seen in conditions like hyponatremia), not the inflammatory process of meningitis.

B.While inflammation is a key part of the body's response in meningitis, the edema is not a result of generalized whole-body inflammation. The edema is more directly linked to local inflammatory reactions in the brain triggered by the pathogen’s by-products.

C.Bacterial cell walls, endotoxins, and other components released by the bacteria directly stimulate inflammation, causing the breakdown of the BBB and allowing fluid and inflammatory cells to leak into the brain tissue.

D.This description is more aligned with the pathophysiology of conditions like hydrocephalus rather than meningitis. In meningitis, cerebral edema is primarily due to the inflammatory response, not abnormal CSF flow.

Choice A Reason:

Higher oxygen saturations of 98% to 99% is inappropriate. A pneumothorax involves the presence of air in the pleural space, which can compromise lung function and gas exchange. This compromised lung function typically leads to decreased oxygenation of the blood, resulting in lower oxygen saturations rather than higher saturations.

Choice B Reason:

Lower oxygen saturations of 93% to 94% is appropriate. A pneumothorax disrupts the normal exchange of oxygen and carbon dioxide in the lungs due to partial or complete lung collapse. As a result, the affected lung is unable to adequately oxygenate the blood, leading to lower oxygen saturations, which are indicative of hypoxemia.

Choice C Reason:

Lower energy expenditure is inappropriate. Energy expenditure is not typically affected by a pneumothorax. While the discomfort and respiratory distress associated with a pneumothorax may cause the individual to limit physical activity, there is no direct impact on overall energy expenditure.

Choice D Reason:

Increased lung capacity is inappropriate. A pneumothorax results in partial or complete collapse of the affected lung, reducing lung capacity rather than increasing it. The presence of air in the pleural space creates positive pressure, which can compress the lung and decrease its ability to expand fully during inhalation.