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,B,D,F

Choice A: Weakened gag reﬂex is a complication of cervical spinal cord injury. The gag reﬂex is a protective mechanism that prevents choking and aspiration. It is controlled by the cranial nerves IX and X, which originate from the brainstem. A cervical spinal cord injury can impair the transmission of nerve impulses from the brainstem to the pharynx and larynx, resulting in a reduced or absent gag reﬂex. This can increase the risk of aspiration pneumonia and respiratory failure.

Choice B: Hyperthermia is a complication of cervical spinal cord injury. Hyperthermia is an abnormally high body temperature, which can be caused by infection, inﬂammation, or environmental factors. A cervical spinal cord injury can disrupt the sympathetic nervous system, which regulates body temperature by controlling blood ﬂow, sweating, and shivering. This can lead to impaired thermoregulation and hyperthermia, especially in hot and humid environments.

Choice C: Absence of bowel sounds is not a complication of cervical spinal cord injury. Bowel sounds are audible noises produced by the movement of gas and ﬂuid through the intestines. They are inﬂuenced by factors such as diet, activity, medication, and bowel motility. A cervical spinal cord injury does not directly aﬀect bowel sounds, but it

can cause neurogenic bowel dysfunction, which is a loss of voluntary control over bowel movements. This can lead to constipation, fecal impaction, or incontinence.

Choice D: Paralysis is a complication of cervical spinal cord injury. Paralysis is a loss of voluntary muscle movement and sensation in a part of the body. It is caused by damage to the motor and sensory neurons that carry signals from the brain to the muscles and skin. A cervical spinal cord injury can damage the neurons that innervate the arms, trunk, legs, and pelvic organs, resulting in quadriplegia or tetraplegia, which is paralysis of all four limbs and the trunk.

Choice E: Polyuria is not a complication of cervical spinal cord injury. Polyuria is an excessive production of urine, which can be caused by diabetes mellitus, diabetes insipidus, diuretics, or kidney disease. A cervical spinal cord injury does not directly aﬀect urine production, but it can cause neurogenic bladder dysfunction, which is a loss of voluntary control over bladder function. This can lead to urinary retention, overﬂow incontinence, or reﬂex incontinence.

Choice F: Hypotension is a complication of cervical spinal cord injury. Hypotension is an abnormally low blood pressure, which can be caused by blood loss, dehydration, shock, or medication. A cervical spinal cord injury can impair the sympathetic nervous system, which regulates blood pressure by controlling heart rate, cardiac output, and vascular tone. This can lead to neurogenic shock, which is a type of distributive shock characterized by hypotension and bradycardia.

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Correct Answer is D

Explanation

Choice A: Weight gain is not a manifestation of left-sided heart failure. Weight gain is more likely to occur in right-sided heart failure, as the blood backs up in the systemic circulation and causes ﬂuid retention and edema in the body.

Choice B: Anorexia is not a manifestation of left-sided heart failure. Anorexia is a loss of appetite, which can have many causes, such as psychological disorders, infections, medications, or cancer. Left-sided heart failure does not directly affect appetite, but it can cause nausea, fatigue, and weakness.

Choice C: A distended abdomen is not a manifestation of left-sided heart failure. A distended abdomen is more likely to occur in right-sided heart failure, as the blood backs up in the portal vein and causes increased pressure in the liver and spleen. This can lead to hepatomegaly, splenomegaly, ascites, and varices.

Choice D: Breathlessness is a manifestation of left-sided heart failure. Breathlessness, or dyspnea, is a sensation of difficulty breathing or shortness of breath. Breathlessness occurs in left-sided heart failure, as the blood backs up in the lungs and causes pulmonary congestion and edema. This impairs gas exchange and reduces oxygen delivery to the tissues.

A. Nausea B. Severe dyspnea C. Headache D. Decreased level of consciousness E. Hypotension

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.

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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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Explanation

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