The nurse is caring for a possible cervical spine (CS) injury with blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min: their skin is warm and flushed. What is the best interpretation of these findings by the nurse?

The patient is experiencing an allergic reaction

The patient is developing neurogenic shock

The vital signs are normal for this patient

The patient most likely has an elevated temperature

Answer and Explanation

The Correct Answer is B

Rationale:
A. The patient is experiencing an allergic reaction is incorrect because while hypotension and tachycardia can occur with anaphylaxis, allergic reactions usually present with rash, urticaria, angioedema, and respiratory compromise. The bradycardia and warm, flushed skin are not typical features of an allergic reaction.

B. The patient is developing neurogenic shock is correct because the findings are classic for neurogenic shock, which occurs with spinal cord injuries, especially above T6. Neurogenic shock results from loss of sympathetic nervous system tone, leading to vasodilation, hypotension, bradycardia, and warm/flushed skin. Respiratory rate may increase as a compensatory response. Unlike other forms of shock, the skin remains warm due to peripheral vasodilation, differentiating it from hypovolemic or cardiogenic shock, which present with cold, clammy skin.

C. The vital signs are normal for this patient is incorrect because BP 70/50 mm Hg and HR 45 beats/min indicate hemodynamic instability, which is not normal, especially in the context of acute trauma.

D. The patient most likely has an elevated temperature is incorrect because warm, flushed skin in neurogenic shock is due to vasodilation, not fever. There is no information in the scenario to suggest infection or hyperthermia.

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Correct Answer is C

Explanation

Rationale:

A. This is an invasive procedure typically reserved for patients with abnormal blood counts, suspected leukemia, or unexplained cytopenias. It is not the first-line diagnostic test for nonspecific post-viral symptoms.

B. This is used to assess for lymphoma or other malignancies when lymphadenopathy is present. It is not indicated for generalized malaise or fatigue without obvious lymph node enlargement.

C. A CBC with differential is a non-invasive, routine test that provides information on red blood cells, white blood cells, hemoglobin, hematocrit, and platelets, as well as types of white blood cells. For a patient presenting with fatigue, malaise, and shortness of breath, a CBC can help identify anemia, leukopenia, or infection as potential causes of these post-viral symptoms.

D. A differential alone evaluates the types of white blood cells but does not assess red blood cells or hemoglobin, which are important when evaluating fatigue or shortness of breath. A CBC with differential provides a more complete assessment.

A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the client has respiratory distress syndrome. C. The client needs immediate intubation and mechanical ventilation." D. "The blood clot interferes with perfusion in the lungs."

Correct Answer is D

Explanation

Rationale:

A. Rapid breathing (tachypnea) alone does not significantly prevent oxygenation. While it may cause fatigue over time, it is not the primary reason oxygen saturation remains low in pulmonary embolism.

B. Acute respiratory distress syndrome (ARDS) is a different condition. While ARDS also impairs oxygenation, the patient has a pulmonary embolism, so the cause of hypoxemia is different.

C. Immediate intubation is not automatically indicated for every patient with pulmonary embolism. Many patients can maintain adequate oxygenation with supplemental oxygen unless they develop severe respiratory failure.

D. A pulmonary embolism obstructs blood flow in the pulmonary arteries, causing a ventilation-perfusion (V/Q) mismatch. Oxygen can reach the alveoli, but blood flow is blocked, so oxygen cannot be effectively transferred into the circulation, resulting in persistent hypoxemia despite supplemental oxygen.

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The nurse is caring for a possible cervical spine (CS) injury with blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min: their skin is warm and flushed. What is the best interpretation of these findings by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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