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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Albumin is a plasma expander and is typically used to restore blood volume in cases of shock, burns, or trauma. However, it is not specifically indicated for managing spinal shock. Albumin helps in maintaining osmotic pressure and fluid balance but does not directly address the underlying pathophysiology of spinal shock.

Choice B reason: Nitroprusside is a potent vasodilator used to manage hypertensive crises. It works by rapidly reducing blood pressure through vasodilation. In the context of spinal shock, where hypotension is a concern, administering nitroprusside would be inappropriate as it could exacerbate the hypotensive state and worsen the patient's condition.

Choice C reason: Dexamethasone, a corticosteroid, is used to reduce inflammation and edema around the spinal cord following an injury. The anti-inflammatory properties of dexamethasone help to mitigate secondary damage caused by swelling and pressure on the spinal cord tissue. It is commonly administered in cases of acute spinal cord injuries to improve neurological outcomes and manage symptoms of spinal shock.

Choice D reason: Furosemide is a diuretic used to manage fluid overload and edema. It works by increasing urine output, which can help reduce fluid retention in various conditions, such as heart failure and renal impairment. However, it is not specifically indicated for the management of spinal shock and does not address the underlying causes of spinal cord injury-related inflammation and edema.

A. Woman with a blood pressure of 158/90 mm Hg. B. Patient with Kussmaul respirations. C. Man with skin itching from head to toe. D. Patient with halitosis and stomatitis.

Correct Answer is B

Explanation

Choice A reason: A blood pressure of 158/90 mm Hg in a patient with chronic kidney disease (CKD) is elevated and requires management to prevent complications. However, it is not as immediately life-threatening as Kussmaul respirations, which indicate severe metabolic acidosis.

Choice B reason: The patient with Kussmaul respirations should be assessed first. Kussmaul respirations are deep, labored breathing patterns typically associated with severe metabolic acidosis, such as diabetic ketoacidosis (DKA) or severe kidney failure. This condition requires immediate intervention to correct the underlying acidosis and stabilize the patient's condition.

Choice C reason: Itching (pruritus) is a common symptom in CKD due to the accumulation of uremic toxins. While it can be very uncomfortable and requires treatment, it is not as urgent as Kussmaul respirations, which indicate a potentially life-threatening situation.

Choice D reason: Halitosis (bad breath) and stomatitis (inflammation of the mouth) can occur in CKD due to the buildup of uremic toxins and other factors. These symptoms need attention, but they do not indicate an immediate threat to the patient's life compared to Kussmaul respirations.

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What findings would the nurse expect when caring for a client who is experiencing spinal shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who experienced a cervical spine injury 12 hours ago and is experiencing spinal shock. Which of the following medications should the nurse anticipate giving?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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