A patient with a cervical neck fracture at the C5 level is admitted to ICU following initial treatment in ER. During initial assessment of the patient, the nurse recognizes the presence of spinal shock upon finding:
Hypotension, bradycardia, and warm extremities.
Involuntary spastic movements of the arms and legs.
Flaccid paralysis and lack of sensation below the level of the injury.
Loss of voluntary motor control, but presence of reflex activity below the level of the injury.
The Correct Answer is C
Choice A rationale
Hypotension, bradycardia, and warm, dry skin are the hallmark signs of neurogenic shock, not necessarily spinal shock. Neurogenic shock results from the loss of sympathetic tone and subsequent massive vasodilation following a high cervical or thoracic cord injury. While it can occur simultaneously with spinal shock, the specific physical assessment finding that defines spinal shock is the temporary loss of all neurological activity, including motor, sensory, and autonomic functions, immediately following the traumatic event.
Choice B rationale
Involuntary spastic movements and hyperreflexia are signs of upper motor neuron damage that typically appear weeks or months after the initial spinal cord injury. During the acute phase of spinal shock, the muscles are incapable of such movements because the reflex arcs are entirely suppressed. Spasticity indicates that the period of spinal shock has ended and that the spinal cord below the level of the injury is starting to function independently of brain control.
Choice C rationale
Spinal shock is characterized by the immediate onset of flaccid paralysis and a complete loss of all sensation and reflex activity below the level of the spinal cord injury. This physiological state occurs because of the sudden cessation of impulses from the higher brain centers. It can last from several days to several weeks. The clinical disappearance of spinal shock is marked by the return of the bulbocavernosus reflex and the gradual development of muscle spasticity.
Choice D rationale
This description characterizes the period following the resolution of spinal shock in a patient with a complete spinal cord injury. Once the shock phase passes, reflex activity often returns because the lower motor neurons remain intact, even though voluntary motor control is lost due to the interruption of descending tracts. During the actual state of spinal shock, there is a total absence of reflex activity, making this choice an incorrect assessment for the initial shock phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An oncology nurse is highly skilled in maintaining sterile techniques and performing complex dressing changes, which are common in cancer care. A patient with partial-thickness burns requiring a dressing change matches the float nurse's existing competency level. This assignment allows the nurse to provide safe, effective care without requiring specialized burn-unit training in hemodynamic resuscitation or graft-specific monitoring, ensuring the patient's wound environment remains protected and the risk of infection is minimized.
Choice B rationale
Discharge teaching for a burn patient involves highly specific knowledge regarding nutrition for hypermetabolic states and specialized wound care for skin grafts. An oncology nurse may not be familiar with the unique caloric requirements (often 4000-5000 calories daily) or the specific appearance of healing grafts versus oncology-related skin breakdown. This task is better suited for a permanent burn unit RN who understands the long-term recovery trajectory and specific complications of thermal injuries.
Choice C rationale
A new admission with burns covering 30 percent of the body surface area is in the critical emergent phase of burn care. This stage requires intensive fluid resuscitation calculations, usually following the Parkland formula, and frequent monitoring of urine output (target 0.5 to 1 mL/kg/hr). The oncology float nurse likely lacks the specialized training required to manage the rapid shifts in capillary permeability and the severe systemic inflammatory response seen in major thermal trauma.
Choice D rationale
Positioning hand splints for a patient with full-thickness burns requires specialized knowledge of occupational therapy goals and the prevention of contractures. Full-thickness burns involve the destruction of the epidermis and dermis, often requiring precise immobilization to maintain function. An oncology nurse would not typically have experience with burn-specific splinting protocols or the assessment of graft adherence under those splints, making this an inappropriate assignment for a nurse floating from a different specialty.
Correct Answer is B
Explanation
Choice A rationale
Critical incident stress management is one approach used for crisis intervention, but it is not the only method available for managing this disorder. Comprehensive treatment often involves a combination of cognitive-behavioral therapy, eye movement desensitization and reprocessing, and pharmacological interventions like selective serotonin reuptake inhibitors. Suggesting it is the sole method ignores the complexity of trauma recovery and the necessity of individualized care plans that integrate various therapeutic modalities for long-term psychological health.
Choice B rationale
Individuals suffering from this condition frequently manifest physical symptoms alongside psychological ones. The chronic activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis leads to somatic complaints. These can include chronic pain, cardiovascular issues, gastrointestinal distress, and tension headaches. The body remains in a state of hyperarousal, meaning the physical manifestations are a direct biological consequence of the trauma-induced stress response, reflecting the intricate link between mental health and physical physiological stability.
Choice C rationale
Professional burnout is actually quite common among individuals experiencing this disorder, particularly for those in high-stress occupations like healthcare or emergency services. The emotional exhaustion and depersonalization associated with the condition significantly increase the risk of occupational burnout. The cognitive load required to manage intrusive thoughts and hypervigilance depletes the individual's professional efficacy and resilience, making the suggestion that burnout is rare in this context scientifically and statistically inaccurate for this population.
Choice D rationale
The manifestations of this disorder are not purely psychological; they involve significant neurobiological changes. Brain imaging often shows alterations in the hippocampus, amygdala, and prefrontal cortex. Furthermore, the autonomic nervous system remains dysregulated, leading to measurable physical changes in heart rate variability, sleep patterns, and cortisol levels. Classifying the disorder as purely psychological ignores the systemic physiological impact that traumatic stress has on the entire human body, including the immune and endocrine systems.
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