An older adult client is diagnosed with a severe urinary tract infection. The nurse assesses the client for which most serious complication?

Choice A reason: Hemothorax is not the correct explanation because it is a condition where blood accumulates in the pleural space, which is the area between the lungs and the chest wall. Hemothorax can cause low blood pressure, rapid breathing, and reduced breath sounds, but it does not cause tracheal deviation, which is a sign of increased pressure in the chest.

Choice B reason: Absorption atelectasis is not the correct explanation because it is a condition where the alveoli, which are the tiny air sacs in the lungs, collapse due to lack of oxygen. Absorption atelectasis can cause reduced breath sounds, but it does not cause low blood pressure, rapid breathing, or tracheal deviation, which are signs of a life-threatening emergency.

Choice C reason: Tension pneumothorax is the correct explanation because it is a condition where air leaks into the pleural space and creates a one-way valve that prevents the air from escaping. This causes the pressure in the chest to increase, which compresses the lung, the heart, and the great vessels. Tension pneumothorax can cause low blood pressure, rapid breathing, absent breath sounds, and tracheal deviation, which are signs of a medical emergency that requires immediate treatment.

Choice D reason: Hypovolemic shock is not the correct explanation because it is a condition where the body loses a large amount of blood or fluid, which reduces the blood volume and the blood pressure. Hypovolemic shock can cause low blood pressure and rapid breathing, but it does not cause absent breath sounds or tracheal deviation, which are signs of a chest injury.

Choice A reason: Decrease in sympathetic nervous system outflow is the best explanation because it is a condition that affects the regulation of blood pressure, heart rate, and skin temperature. The sympathetic nervous system is a part of the autonomic nervous system, which is the part of the nervous system that controls the involuntary functions of the body, such as breathing, digestion, and circulation. The sympathetic nervous system is responsible for the fight-or-flight response, which prepares the body for action or danger, by increasing the blood pressure, heart rate, and skin temperature. The sympathetic nervous system is composed of nerve fibers that originate from the thoracic and lumbar regions of the spinal cord, which are the middle and lower parts of the spinal cord. A complete spinal cord injury at the C3 to C4 level is a condition where the spinal cord is severed or damaged at the neck, which interrupts the communication between the brain and the rest of the body. A complete spinal cord injury at the C3 to C4 level can cause the loss of sympathetic nervous system outflow, which means that the nerve impulses that normally stimulate the blood vessels, the heart, and the sweat glands are reduced or absent. This can result in hypotension, which is a low blood pressure, bradycardia, which is a slow heart rate, and warm and dry skin, which are the observations noted in the client.

Choice B reason: Decreased fluid volume in the intravascular space is not the best explanation because it is a condition that affects the amount of fluid in the blood vessels, which can be caused by various factors, such as dehydration, bleeding, or vomiting. Decreased fluid volume in the intravascular space can cause hypotension, which is a low blood pressure, but it can also cause tachycardia, which is a fast heart rate, and cool and clammy skin, which are not the observations noted in the client.

Choice C reason: The effects of opiate medication administration is not the best explanation because it is a condition that affects the pain perception and the central nervous system, which can be caused by various types of medications, such as morphine, codeine, or oxycodone. The effects of opiate medication administration can cause hypotension, which is a low blood pressure, and bradycardia, which is a slow heart rate, but it can also cause respiratory depression, which is a slow and shallow breathing, and miosis, which is a constriction of the pupils, which are not the observations noted in the client.

Choice D reason: Onset of acute systemic bacterial infection is not the best explanation because it is a condition that affects the immune system and the whole body, which can be caused by various types of bacteria, such as staphylococcus, streptococcus, or salmonella. Onset of acute systemic bacterial infection can cause hypotension, which is a low blood pressure, but it can also cause fever, which is a high body temperature, and chills, which are sensations of coldness and shivering, which are not the observations noted in the client.