A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Increased oxygen saturation.

Urine output less than 30 mL/hr.

Decreased level of consciousness.

Heart rate of 34 beats/min.

Answer and Explanation

Correct Answer : B,D

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

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Correct Answer is A

Explanation

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

A. Young adults ages 12-20. B. Young men ages 16-30. C. Children ages 2-15. D. Elderly people ages 60 and up.

Correct Answer is B

Explanation

Choice A reason:

Young adults ages 12-20 are at risk for spinal cord injuries due to sports and recreational activities. However, the highest risk group for spinal cord injuries, particularly from activities such as motor vehicle accidents and risky behaviors, is young men ages 16-30.

Choice B reason:

Young men ages 16-30 are the highest risk group for spinal cord injuries. This population is more likely to engage in high-risk activities such as driving, contact sports, and recreational activities that can lead to spinal cord injuries. Therefore, they would benefit most from targeted prevention education.

Choice C reason:

Children ages 2-15 are at risk for spinal cord injuries, particularly from falls and accidents. However, their risk is lower compared to the young adult male population. Education for this group is important but not as critical as for young men.

Choice D reason:

Elderly people ages 60 and up are at risk for spinal cord injuries, primarily from falls. While prevention education is important for this group, they are not the highest risk population compared to young men ages 16-30.

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A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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