A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Choice A reason:

While explaining discharge instructions is an important part of patient education and ensuring safety after leaving the hospital, it is not the immediate priority. The nurse must first address any potential medical issues that could compromise the patient's health, such as circulation and nerve function in the affected limb.

Choice B reason:

Applying an ice pack to the casted leg can help reduce swelling and provide comfort to the client. This is often recommended for the first 24 to 72 hours after the cast is applied, especially if the cast is on a leg. However, this is secondary to assessing the neurovascular status of the limb.

Choice C reason:

Performing a neurovascular assessment is the priority action for the nurse. This assessment includes checking for sensation, warmth, capillary refill, pulses, and movement. It is crucial to identify any signs of compromised blood flow or nerve injury early to prevent further complications.

Choice D reason:

Providing reassurance to the client and parents is important for emotional support and can help alleviate anxiety. However, the nurse's immediate priority is to ensure the physical well-being of the client, which includes performing a neurovascular assessment to detect any urgent issues.

Choice A reason: Hypertension
Hypertension, or high blood pressure, is not typically an expected finding in hypovolemic shock. In fact, one would expect the opposite, hypotension, due to the decreased circulating blood volume. Hypertension might be present in the initial stages due to compensatory mechanisms, but as the condition progresses, blood pressure usually drops.

Choice B reason: Bradypnea
Bradypnea, or abnormally slow breathing, is not a common finding in hypovolemic shock. Instead, tachypnea, or rapid breathing, may be observed as the body attempts to compensate for reduced oxygen delivery to tissues.

Choice C reason: Oliguria
Oliguria, or low urine output, is an expected finding in hypovolemic shock. As the blood volume decreases, the kidneys receive less blood flow, leading to reduced urine production. This is a protective mechanism to conserve body fluids, but it also indicates the severity of fluid loss and the need for urgent intervention.

Choice D reason: Flushing of the skin
Flushing of the skin is not an expected finding in hypovolemic shock. Instead, the skin may appear pale, cool, and clammy due to vasoconstriction and reduced blood flow to the periphery as the body prioritizes blood flow to vital organs.