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 D
Explanation
Choice A Reason:
Bronchopneumonia is incorrect. Bronchopneumonia is characterized by patchy areas of consolidation involving multiple lobules scattered throughout the lungs. It typically results from bronchial obstruction and aspiration of infected material into the smaller airways and alveoli.
Choice B Reason:
Severe pneumonia is incorrect. "Severe pneumonia" is a broad term that can refer to pneumonia with various degrees of severity. It does not specifically describe the pattern of consolidation involving the entire lobe of the lung.
Choice C Reason:
Empyema is incorrect. Empyema refers to the accumulation of pus in the pleural cavity, often as a complication of pneumonia. It does not describe the pattern of consolidation within the lung tissue.
Choice D Reason:
Lobar pneumonia is correct. Lobar pneumonia is characterized by consolidation involving an entire lobe or lobes of the lung. It typically results from infection by a single pathogen, such as Streptococcus pneumoniae, which leads to inflammation and consolidation of an entire lobe of the lung.
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason:
Loss of teeth is not typically considered a direct factor contributing to obstructive sleep apnea. While the presence of teeth may play a role in maintaining the structure of the oral cavity, it is not a primary risk factor for OSA.
Choice B Reason:
Stroke is correct. Individuals who have had a stroke are at increased risk of developing obstructive sleep apnea. Stroke can cause damage to areas of the brain involved in controlling breathing and upper airway function, leading to disruptions in respiratory control during sleep.
Choice C Reason:
Sleepiness is a symptom commonly associated with obstructive sleep apnea rather than a direct contributing factor. Excessive daytime sleepiness is a consequence of disrupted sleep patterns and recurrent episodes of breathing cessation during the night, which are characteristic features of obstructive sleep apnea.
Choice D Reason:
Fatty deposits is correct. Excessive fatty deposits, particularly around the neck and throat, can contribute to the narrowing and collapse of the upper airway during sleep, increasing the risk of obstructive sleep apnea. Obesity is a significant risk factor for OSA due to the accumulation of fat deposits in the upper airway tissues.
Choice E Reason:
Muscle dysfunction is correct. Muscle dysfunction, particularly of the muscles surrounding the upper airway, can impair the ability of these muscles to keep the airway open during sleep. Weakness or dysfunction of these muscles can lead to increased collapsibility of the upper airway, contributing to obstructive sleep apnea.
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