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 ["B","C","D","E"]

Explanation

Choice a) is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of discomfort in the stomach that may or may not lead to vomiting. Nausea can be caused by many other conditions, such as gastroenteritis, motion sickness, or pregnancy.

Choice b) is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective feeling of difficulty or discomfort in breathing. Severe dyspnea indicates that the client is not getting enough oxygen and may have low blood oxygen levels (hypoxemia) or high carbon dioxide levels (hypercapnia).

Choice c) is correct because headache is a common manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can be caused by high carbon dioxide levels (hypercapnia), which can affect the blood vessels and nerves in the brain.

Choice d) is correct because a decreased level of consciousness is a common manifestation of ARF. Level of consciousness is a measure of how alert and oriented a person is. A decreased level of consciousness can be caused by low blood oxygen levels (hypoxemia), high carbon dioxide levels (hypercapnia), or acid-base imbalance, which can aﬀect brain function and mental status.

Choice e) is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal. Hypotension can be caused by low blood oxygen levels (hypoxemia), which can impair heart function and reduce cardiac output.

A. Widening pulse pressure B. Increased heart rate C. Increased deep tendon reﬂexes D. Pulse oximetry 96%

Correct Answer is B

Explanation

Choice A Reason: This is incorrect. Widening pulse pressure is not a sign of hypovolemic shock, but rather of increased intracranial pressure or aortic regurgitation. Hypovolemic shock causes narrowing pulse pressure due to decreased stroke volume and increased peripheral resistance.

Choice B Reason: This is correct. Increased heart rate is a sign of hypovolemic shock, as the body tries to compensate for the decreased blood volume and cardiac output by increasing the heart rate and contractility.

Choice C Reason: This is incorrect. Increased deep tendon reﬂexes are not a sign of hypovolemic shock, but rather of hyperreﬂexia or tetany. Hypovolemic shock causes decreased deep tendon reﬂexes due to reduced perfusion and oxygenation of the muscles and nerves.

Choice D Reason: This is incorrect. Pulse oximetry 96% is not a sign of hypovolemic shock, but rather of normal oxygen saturation. Hypovolemic shock causes decreased pulse oximetry due to hypoxia and impaired gas exchange.

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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.)

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Explanation

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Explanation

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