What findings would the nurse expect when caring for a client who is experiencing spinal shock?
Hypotension and a decreased level of consciousness.
Stridor, garbled speech, or inability to clear airway.
Bradycardia and decreased urinary output.
Temporary loss of motor, sensory, reflex, and autonomic function.
The Correct Answer is D
Choice A reason: Hypotension and a decreased level of consciousness can occur in spinal shock due to the disruption of the sympathetic nervous system, but these are not the hallmark features. They are more secondary effects rather than the primary presentation.
Choice B reason: Stridor, garbled speech, or inability to clear the airway are not typical findings in spinal shock. These symptoms are more indicative of airway obstruction or respiratory distress, which are not directly related to spinal shock.
Choice C reason: Bradycardia and decreased urinary output can occur in spinal shock due to the loss of sympathetic tone, leading to unopposed parasympathetic activity. While these are relevant symptoms, they do not encompass the full scope of spinal shock.
Choice D reason: The primary findings in spinal shock are the temporary loss of motor, sensory, reflex, and autonomic function below the level of the spinal injury. This includes flaccid paralysis, loss of reflexes, and autonomic dysfunction, such as hypotension and bradycardia. These symptoms are the most defining characteristics of spinal shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Vasopressin (Desmopressin) is not primarily used to decrease blood pressure. It is an antidiuretic hormone that helps manage diabetes insipidus by reducing urine output. While vasopressin can have vasoconstrictive effects, its primary role in this context is to control urine production, not blood pressure.
Choice B reason: The primary therapeutic outcome of vasopressin (Desmopressin) in a patient with diabetes insipidus is to decrease urine output. Diabetes insipidus leads to excessive urine production and dehydration. Vasopressin acts on the kidneys to increase water reabsorption, thereby reducing urine volume and helping to maintain fluid balance.
Choice C reason: Level of consciousness is not a direct therapeutic outcome of vasopressin (Desmopressin). While managing fluid balance can indirectly affect a patient's overall condition and well-being, vasopressin specifically targets the kidneys to reduce urine output and does not have a direct impact on consciousness levels.
Choice D reason: Specific gravity refers to the concentration of solutes in the urine. While vasopressin can affect the specific gravity by concentrating the urine and reducing volume, the primary therapeutic goal is to manage urine output in patients with diabetes insipidus. The focus is on reducing the excessive urine production rather than altering specific gravity.
Correct Answer is B
Explanation
Choice A reason: Administering 2 tablets of digoxin 0.125 mg would provide the correct dosage of 0.25 mg. However, given the client's heart rate of 54/min, administering the medication could further lower the heart rate, which can be dangerous. The nurse should withhold the medication and notify the physician.
Choice B reason: Withholding the digoxin dose for decreased heart rate is the correct action. Digoxin is used to slow down the heart rate and strengthen heart contractions. A heart rate of 54/min is considered bradycardia (slow heart rate), and administering digoxin could exacerbate the bradycardia, leading to potential complications such as heart block or severe arrhythmias. Therefore, it is critical to withhold the medication and inform the physician of the client's current heart rate.
Choice C reason: Administering one tablet of digoxin 0.125 mg would not provide the full prescribed dose of 0.25 mg. More importantly, the client's low heart rate makes it unsafe to administer any dose of digoxin at this time.
Choice D reason: Withholding the digoxin dose for elevated blood pressure is not appropriate. Although the client has elevated blood pressure (144/96), the more immediate concern is the low heart rate. Digoxin affects heart rate more than blood pressure, and the risk of exacerbating bradycardia takes precedence.
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