A nurse is assessing a client who has a spinal cord injury with heterotopic ossifications. Which of the following findings should the nurse expect?
Hypertension
Bradycardia
Fecal impaction
Arthralgia
The Correct Answer is D
Choice A Reason:
Hypertension is not typically associated with heterotopic ossifications. However, it may occur in individuals with spinal cord injuries (SCI) due to autonomic dysreflexia, a condition characterized by an exaggerated sympathetic response to stimuli below the level of injury. Autonomic dysreflexia can lead to a sudden increase in blood pressure, which, if left untreated, can result in complications such as stroke or seizure. However, hypertension is not directly related to heterotopic ossifications.
Choice B Reason:
Bradycardia is also not typically associated with heterotopic ossifications. Like hypertension, bradycardia may occur in individuals with SCI due to autonomic dysreflexia. Autonomic dysreflexia can lead to a sudden increase in blood pressure and a reflex bradycardia in response to the increased sympathetic outflow. However, bradycardia is not directly related to heterotopic ossifications.
Choice C Reason:
Fecal impaction is a potential complication of spinal cord injury (SCI) due to impaired bowel function, but it is not directly related to heterotopic ossifications. SCI can disrupt normal bowel motility and result in neurogenic bowel dysfunction, leading to symptoms such as constipation, fecal impaction, and bowel obstruction. However, fecal impaction is not specific to heterotopic ossifications.
Choice D Reason:
Arthralgia is correct. Heterotopic ossifications (HO) involve the abnormal formation of bone in soft tissues around joints, muscles, tendons, or ligaments. When HO occurs around joints, it can lead to symptoms such as pain, swelling, and decreased range of motion, collectively known as arthralgia. Therefore, arthralgia is a common finding associated with heterotopic ossifications in individuals with spinal cord injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Osteoporosis is inappropriate. Chronic respiratory acidosis can lead to osteoporosis over time due to several factors, including chronic hypoxemia, which can affect bone metabolism and lead to bone loss.
Choice B Reason:
Polyuria is inappropriate. Polyuria, or increased urination, is not typically associated with chronic respiratory acidosis. In fact, respiratory acidosis tends to cause retention of bicarbonate ions, which can lead to compensatory metabolic alkalosis and decreased urine output.
Choice C Reason:
Anxiety and depression is inappropriate. Chronic respiratory acidosis can lead to symptoms such as lethargy, confusion, and decreased mental acuity due to the effects of elevated CO2 levels on the central nervous system. While anxiety and depression are not direct consequences of chronic respiratory acidosis, individuals with COPD may experience anxiety and depression as a result of their chronic respiratory condition.
Choice D Reason:
Delirium is correct. Delirium, characterized by an acute change in mental status, confusion, and altered consciousness, can occur in severe cases of chronic respiratory acidosis, especially during acute exacerbations. Elevated CO2 levels can affect brain function and lead to symptoms of delirium.
Correct Answer is A
Explanation
Choice A Reason:
Hypertension is correct. This is a modifiable risk factor for stroke. Hypertension, or high blood pressure, significantly increases the risk of stroke. Treating and controlling hypertension through lifestyle changes and medication can help reduce the risk of stroke.
Choice B Reason:
Client's age is incorrect. While age itself is not modifiable, age is a non-modifiable risk factor for stroke. Risk of stroke increases with age, particularly in individuals over 55 years old. However, other modifiable risk factors can be addressed to reduce overall risk.
Choice C Reason:
History of sickle cell disease is incorrect. Sickle cell disease is a genetic disorder characterized by abnormal hemoglobin in red blood cells. While sickle cell disease increases the risk of certain complications, such as stroke in children, it is not a modifiable risk factor in the traditional sense.
Choice D Reason:
Parent who has cardiovascular disease is incorrect. While having a parent with cardiovascular disease may indicate a genetic predisposition to certain risk factors, it is not a direct modifiable risk factor for stroke. However, individuals with a family history of cardiovascular disease may have increased awareness and motivation to address modifiable risk factors such as hypertension, smoking, and diabetes.
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