A nurse is caring for a client who has bipolar disorder

Exhibits

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After assessing the client and reviewing the client's medical record, the nurse determines that the client could be experiencing which of the following?

The client could be experiencing

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A. Hypotension: Clients with cervical spinal cord injuries are at risk for neurogenic shock, which disrupts sympathetic nervous system output. This results in peripheral vasodilation, leading to hypotension and bradycardia, especially in injuries above T6.

B. Polyuria: Polyuria is not typically associated with acute cervical spinal cord injuries. Spinal cord injuries can sometimes lead to issues with bladder control, such as urinary retention or neurogenic bladder, which may manifest as overflow incontinence, not typically polyuria.

C. Hyperthermia: Cervical spinal cord injuries can impair thermoregulation due to autonomic nervous system disruption. The body may have difficulty sweating or adjusting blood flow to the skin, which can result in hyperthermia, especially in warm environments.

D. Absence of bowel sounds: Neurogenic shock and loss of autonomic regulation can lead to decreased gastrointestinal motility, resulting in paralytic ileus. This may present as absent or hypoactive bowel sounds in the acute phase of injury.

E. Weakened gag reflex: High cervical spinal cord injuries can impair cranial nerve function and compromise airway protective reflexes. A weakened gag reflex increases the risk of aspiration and may require airway protection through intubation or suctioning.

• +1 posterior tibial pulse: A diminished pulse supports arterial insufficiency and is frequently seen in both arterial and diabetic ulcers due to vascular complications in diabetes. Venous ulcers usually have normal pulses unless complicated by edema.
• Hair loss: Loss of hair on the lower extremities is a classic sign of arterial insufficiency, but it is also common in diabetic neuropathy where circulation is impaired. Venous ulcers rarely show this sign.
• History of hypertension: Hypertension is a risk factor for arterial disease, venous insufficiency (due to increased venous pressure), and diabetes-related vascular complications, making it relevant to all three ulcer types.
• Pale wound bed: Pallor in the wound bed suggests poor oxygenation and perfusion, which is characteristic of arterial ulcers. Diabetic ulcers may also have poor granulation due to impaired healing. Venous ulcers are more often red and moist.
• Pain at ulcer site: Pain with walking that improves with rest suggests intermittent claudication and ischemia, consistent with arterial ulcers. Diabetic ulcers can also be painful, especially if infection or inflammation is present. Venous ulcers tend to cause more aching or heaviness rather than sharp pain.
• Defined edges: Ulcers with sharply demarcated, punched-out edges are typical of arterial and diabetic ulcers. Venous ulcers usually have irregular, shallow borders.
• Skin cool to touch of the affected extremity: Cool skin reflects decreased blood flow and is characteristic of arterial ulcers. It is also common in diabetic ulcers due to associated peripheral artery disease. Venous ulcers tend to have warm, swollen limbs due to fluid accumulation.