A nurse is assessing a client who has a spinal cord injury. Which of the following assessment findings should the nurse expect with neurogenic shock? (Select all that apply.)
(Select All that Apply.)
Temperature 36.3° C (97.4° F)
Respirations 12/min
Blood pressure 184/88 mm Hg
Heart rate 54/min
Calcium level 7.0 mg/dL
Correct Answer : A,D
Choice A Reason:
Temperature 36.3°C (97.4°F) is correct. Hypothermia is a characteristic finding in neurogenic shock due to the loss of sympathetic control over temperature regulation and peripheral vasodilation. This can lead to heat loss from the skin surface and a decrease in core body temperature.
Choice B Reason:
Respirations 12/min is incorrect. Respiratory rate is usually not significantly affected in neurogenic shock. However, individuals with high cervical or upper thoracic spinal cord injuries may experience respiratory compromise due to paralysis of respiratory muscles, but this is not a typical feature of neurogenic shock.
Choice C Reason:
Incorrect: Neurogenic shock typically results in hypotension (low blood pressure) due to vasodilation. The given blood pressure reading is elevated, which is not consistent with neurogenic shock.
Choice D Reason:
Heart rate 54/min is correct. Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity resulting from the loss of sympathetic tone. The heart rate may be slow and may decrease further over time.
Choice E Reason:
Calcium level 7.0 mg/dL is incorrect, Calcium levels are not directly related to neurogenic shock. Neurogenic shock primarily involves the loss of sympathetic tone and the resulting hemodynamic changes, rather than alterations in calcium metabolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A Reason:
Decreased visual acuity is correct. Yes, decreased visual acuity, including issues such as poor depth perception, reduced peripheral vision, and difficulty with contrast sensitivity, can contribute to falls and head injuries in older adults.
Choice B Reason:
Motor vehicle crashes is incorrect. While motor vehicle crashes can cause head injuries in individuals of all ages, they are less common among older adults compared to younger age groups.
Choice C Reason:
Polypharmacy is correct. Yes, polypharmacy, which refers to the use of multiple medications concurrently, is a common risk factor for falls and head injuries in older adults. Certain medications, especially those with sedative or psychotropic effects, can increase the risk of falls and accidents.
Choice D Reason:
Weakness is correct. Yes, weakness, frailty, and decreased muscle strength are common age-related changes that can increase the risk of falls and subsequent head injuries in older adults.
Choice E Reason:
Chronic hypertension, particularly when poorly controlled, can contribute to an increased risk of falls in older adults through various mechanisms:Hypertension medications or the condition itself can lead to orthostatic hypotension. This can cause dizziness or lightheadedness, increasing the risk of falls.Chronic hypertension is a major risk factor for cerebrovascular disease, including strokes. These events can lead to neurological deficits such as weakness, numbness, or impaired balance, predisposing individuals to falls.
Choice F Reason:
Previous military experience is incorrect. While previous military experience may contribute to certain health conditions or injuries in older adults, it is not a common reason for head injuries specifically related to falls or accidents in this population.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A Reason:
Paresthesia is appropriate. Paresthesia, or abnormal sensations such as tingling, numbness, or burning, is a common neurological symptom in individuals with multiple sclerosis. It results from damage to the nerves or disruption of nerve signals in the central nervous system.
Choice B Reason:
Nausea and vomiting is inappropriate. While nausea and vomiting can occur in individuals with multiple sclerosis, they are not considered hallmark symptoms of the disease. These symptoms may be associated with other factors such as medications, autonomic dysfunction, or complications such as urinary tract infections.
Choice C Reason:
Dysphagia is appropriate. Dysphagia, or difficulty swallowing, is a common symptom in individuals with multiple sclerosis, particularly as the disease progresses. It can result from damage to the nerves that control swallowing muscles or from impaired coordination of swallowing reflexes.
Choice D Reason:
Spasticity is appropriate. Spasticity, or muscle stiffness and involuntary muscle contractions, is a common symptom in individuals with multiple sclerosis. It occurs due to damage to the nerve fibers that control muscle movement and can lead to difficulty with movement, walking, and muscle control.
Choice E Reason:
Vertigo is appropriate. Vertigo, or the sensation of spinning or dizziness, can occur in individuals with multiple sclerosis, particularly if lesions develop in areas of the brain involved in balance and coordination.
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