A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Weakened gag reﬂex

Hyperthermia

Absence of bowel sounds

Paralysis

Polyuria

Hypotension

Answer and Explanation

Correct Answer : A,C,D,F

Choice A: A cervical spinal cord injury can impair the function of cranial nerves, leading to a weakened gag reflex and an increased risk of aspiration.

Choice B: Patients with spinal cord injuries are more likely to experience poikilothermia (difficulty regulating body temperature), but this often results in hypothermia, not hyperthermia, due to the loss of autonomic temperature control.

Choice C: Spinal shock, which often follows a spinal cord injury, can cause decreased or absent bowel sounds due to a temporary loss of autonomic function and decreased peristalsis.

Choice D: Depending on the level and severity of the injury, paralysis can occur, affecting motor function below the injury site. A cervical spinal cord injury may lead to quadriplegia (tetraplegia).

Choice E: Clients with spinal cord injuries are more likely to experience urinary retention, rather than polyuria, due to loss of bladder control and autonomic dysfunction. A foley catheter may be needed initially, followed by intermittent catheterization.

Choice F: Neurogenic shock, a potential complication of cervical spinal cord injuries, can cause hypotension due to the loss of sympathetic nervous system control over blood vessel tone, leading to vasodilation and bradycardia.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be inﬂuenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reﬂect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reﬂects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and aﬀect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be inﬂuenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

A. Smallpox B. Hydrogen cyanide C. Botulism D. Anthrax E. Sarin

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason: This is correct because smallpox is a highly contagious and deadly viral disease that can be used as a biological weapon. Smallpox was eradicated in 1980, but some samples of the virus are still stored in laboratories. If released intentionally, smallpox could cause a global pandemic.

Choice B Reason: This is incorrect because hydrogen cyanide is a chemical weapon of mass destruction, not a biological one. Hydrogen cyanide is a colorless gas that interferes with cellular respiration and causes rapid death.

Choice C Reason: This is correct because botulism is a serious and potentially fatal illness caused by a toxin produced by the bacterium Clostridium botulinum. Botulism can be used as a biological weapon by contaminating food or water supplies or by aerosolizing the toxin.

Choice D Reason: This is correct because anthrax is an infection caused by the spore-forming bacterium Bacillus anthracis. Anthrax can be used as a biological weapon by releasing the spores into the air or by contaminating food or water sources.

Choice E Reason: This is incorrect because sarin is a chemical weapon of mass destruction, not a biological one. Sarin is a nerve agent that blocks the transmission of nerve impulses and causes respiratory failure and death.

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A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Nursing Test Bank

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