The nurse provides care for a client diagnosed with complete spinal cord injury at the third and fourth cervical (C3 to C4) level that occurred six hours ago. The client's BP is 82/42 mm Hg, apical heart rate is 96 beats/min, and the skin is warm and dry. Which explanation is best for these observations?

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.

Choice A reason: "Are you experiencing any nausea at this time?" is not the highest priority question because it is a common side effect of anesthesia, which is usually given during a thyroidectomy. Nausea is not a life-threatening complication, and it usually resolves within a few days after surgery.

Choice B reason: "Have you noticed any decrease in muscle weakness?" is not the highest priority question because it is a sign of improvement in the client's condition. A subtotal thyroidectomy is a surgical procedure that removes part of the thyroid gland, which is responsible for producing hormones that regulate the metabolism, growth, and development of the body. A client who has a thyroidectomy may have hypothyroidism, which is a condition where the thyroid gland does not produce enough hormones, causing symptoms such as fatigue, weight gain, and muscle weakness. A decrease in muscle weakness indicates that the client is responding well to the hormone replacement therapy, which is usually given after a thyroidectomy.

Choice C reason: "Do you have any numbness or tingling of your hands?" is the highest priority question because it is a sign of a possible complication of a thyroidectomy, which is hypocalcemia. Hypocalcemia is a condition where the blood has a low level of calcium, which is an electrolyte that helps regulate the nerve and muscle function, including the heart. A thyroidectomy can cause hypocalcemia if the parathyroid glands, which are small glands that are located behind the thyroid gland and produce a hormone that regulates the calcium level in the blood, are accidentally damaged or removed during the surgery. Hypocalcemia can cause symptoms such as numbness and tingling of the hands, feet, and lips, muscle spasms, seizures, and cardiac arrhythmias, which can be fatal if not treated promptly.

Choice D reason: "Do you have any breathing difficulties while walking?" is not the highest priority question because it is a sign of a possible complication of a thyroidectomy, which is tracheal compression. Tracheal compression is a condition where the trachea, which is the airway that connects the mouth and nose to the lungs, is squeezed or narrowed by the swelling or bleeding of the tissues around the thyroid gland. Tracheal compression can cause symptoms such as difficulty breathing, hoarseness, stridor, and cyanosis, which can be life-threatening if not treated promptly. However, tracheal compression is more likely to occur immediately after surgery, not 48 hours later.