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 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. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg B. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg C. pH 7.50, HCO3- 26 mEq/L, PaCO2 50 mm Hg D. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because these values indicate respiratory alkalosis, which is caused by hyperventilation or excess loss of carbon dioxide (PaCO2). Respiratory alkalosis increases the blood pH and decreases the HCO3- level.

Choice B Reason: This is incorrect because these values indicate metabolic alkalosis, which is caused by excess intake or retention of bases or loss of acids. Metabolic alkalosis increases the blood pH and the HCO3- level.

Choice C Reason: This is incorrect because these values indicate respiratory acidosis, which is caused by hypoventilation or excess retention of carbon dioxide (PaCO2). Respiratory acidosis decreases the blood pH and increases the HCO3- level.

Choice D Reason: This is correct because these values indicate metabolic acidosis, which is a common complication of chronic kidney disease. These values indicate metabolic acidosis, which is a common complication of chronic kidney disease. Metabolic acidosis occurs when the kidneys are unable to excrete excess acids or retain enough bicarbonate (HCO3-), which is a base that buﬀers the blood pH. As a result, the blood pH decreases and becomes more acidic. The normal range for blood pH is 7.35 to 7.45, for HCO3- is 22 to 26 mEq/L, and for PaCO2 is 35 to 45 mm Hg.

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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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