A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:
Flaccid paralysis and lack of sensation below the level of the injury
Hypotension, bradycardia, and warm extremities
Presence of hyperactive reflex activity below the level of the injury
Severe headache, hypertension, and flushed face
The Correct Answer is A
Choice A reason:
Flaccid paralysis and lack of sensation below the level of the injury are classic signs of spinal shock. Spinal shock is characterized by a temporary loss of all reflexes, motor, and sensory activity below the level of injury, which typically occurs immediately following the injury. Recognizing these signs is crucial for the timely management of the condition.
Choice B reason:
Hypotension, bradycardia, and warm extremities are more indicative of neurogenic shock rather than spinal shock. Neurogenic shock results from the loss of sympathetic tone following a spinal cord injury, leading to cardiovascular changes. These signs do not specifically indicate spinal shock.
Choice C reason:
The presence of hyperactive reflex activity below the level of the injury is not associated with spinal shock. Spinal shock involves the loss of reflex activity rather than hyperactivity. Hyperactive reflexes might develop later as the spinal cord recovers from the initial shock phase.
Choice D reason:
Severe headache, hypertension, and flushed face are symptoms more commonly associated with autonomic dysreflexia, not spinal shock. Autonomic dysreflexia occurs in patients with spinal cord injuries at or above the T6 level and is a response to a noxious stimulus below the level of injury. These symptoms are not indicative of spinal shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.
Choice B reason:
Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.
Choice C reason:
Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.
Choice D reason:
Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.
Choice E reason:
Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.
Correct Answer is B
Explanation
Choice A reason:
A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.
Choice B reason:
A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.
Choice C reason:
A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.
Choice D reason:
A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.
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