A young adult male client is admitted to the emergency department (ED) following a motor vehicle collision and the nurse suspects that he has suffered a spinal cord injury (SCI). Which assessment finding, if present, will alert the nurse to suspect spinal shock?

Dilated pupils.

Hypertension.

Tachycardia.

Absence of reflexes.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Dilated pupils: Pupil dilation is typically associated with increased intracranial pressure, hypoxia, or sympathetic stimulation, not spinal shock. It reflects neurological or ocular changes but does not indicate the loss of spinal reflex activity.

B. Hypertension: Spinal shock causes loss of sympathetic tone, leading to hypotension rather than hypertension. Elevated blood pressure is more characteristic of autonomic dysreflexia, which occurs later in the course of spinal cord injury, not during the initial shock phase.

C. Tachycardia: Spinal shock usually results in bradycardia due to unopposed parasympathetic activity. Tachycardia is inconsistent with the physiological response seen in spinal shock and would more likely indicate pain, anxiety, or hypovolemia.

D. Absence of reflexes: The hallmark of spinal shock is the complete but temporary loss of all motor, sensory, and reflex activity below the level of injury. This areflexia occurs because of sudden interruption of neuronal communication and typically resolves as the spinal cord recovers from the acute insult.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices

• Rupture: The client’s 8.6 cm abdominal aortic aneurysm (AAA) represents a critical dilation far exceeding the typical surgical threshold of 5.5 cm. At this size, the risk of rupture is extremely high because the aortic wall tension increases exponentially as diameter enlarges. The client’s escalating pain intensity in the back and abdomen also signals potential aneurysmal wall weakening or impending rupture.

• Hypertension: Chronic hypertension exerts continuous high pressure on arterial walls, contributing to both aneurysm formation and rupture risk. Elevated systolic pressures accelerate vessel wall degeneration and increase tension on the dilated aorta, especially in elderly patients with atherosclerosis. This client’s medical history of long-term hypertension and vascular disease significantly elevates his rupture risk.

Rationale for Incorrect Choices

• Occlusion: While aneurysms can rarely thrombose and obstruct blood flow, occlusion is not the predominant or immediate risk. The client’s symptoms are more consistent with wall expansion rather than clot formation or arterial blockage.

• Dissection: Aortic dissection involves a tear in the intimal layer allowing blood to separate vessel wall layers, typically presenting with sudden, sharp, tearing chest or back pain. This client’s gradual onset of gnawing pain and imaging showing aneurysmal dilation (not a dissection flap) indicate a degenerative aneurysm rather than a dissection.

• Smoking: Although smoking contributes to aneurysm development by weakening vascular walls through oxidative damage, it is not the highest risk factor for rupture. The acute rupture risk correlates more closely with hypertension-driven wall stress than with smoking history.

• Hyperlipidemia: Hyperlipidemia promotes atherosclerosis, which predisposes to aneurysm formation, but it is less directly linked to aneurysm rupture. The immediate rupture risk arises from hemodynamic strain caused by poorly controlled blood pressure rather than lipid levels.

A. Chest circumference B. Arterial blood gas (ABG) results C. Bubbling in the water seal chamber D. Daily weights E. Peak flow meter values F. Developmentally appropriate pain rating

Correct Answer is ["B","C","F"]

Explanation

Rationale:
A. Chest circumference: Measuring chest circumference is typically used to monitor for bleeding or swelling in infants or postoperative chest surgery patients, not in routine chest tube monitoring. It provides limited information about respiratory function or tube effectiveness in this adult client.

B. Arterial blood gas (ABG) results: ABGs help assess oxygenation, ventilation, and acid-base balance following chest tube placement. They are essential to determine whether the lung is adequately re-expanded and gas exchange is improving after a pneumothorax or effusion.

C. Bubbling in the water seal chamber: Bubbling in the water seal chamber indicates air movement within the pleural space. Continuous bubbling suggests an air leak, while intermittent bubbling may occur during expiration. Monitoring this helps assess chest tube function and detect complications.

D. Daily weights: Although useful for tracking fluid balance, daily weights are not directly relevant to evaluating chest tube effectiveness or respiratory status in this context. They do not reflect immediate pulmonary improvements.

E. Peak flow meter values: Peak flow measurement is typically used in asthma or obstructive airway disorders to monitor expiratory effort. It is not an appropriate indicator of lung re-expansion or pleural drainage after chest tube insertion.

F. Developmentally appropriate pain rating: Pain can interfere with breathing, coughing, and mobility, leading to poor lung expansion. Monitoring pain using a tool appropriate for the client’s developmental level ensures comfort and promotes effective respiratory function post-procedure.

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A young adult male client is admitted to the emergency department (ED) following a motor vehicle collision and the nurse suspects that he has suffered a spinal cord injury (SCI). Which assessment finding, if present, will alert the nurse to suspect spinal shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Patient Data Exhibits Which are important to monitor in this client following the chest tube placement? Select all that apply.

Correct Answer is ["B","C","F"]

Explanation

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