A nurse is caring for a client who has chronic respiratory acidosis due to chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect with this client?

Choice A Reason:

Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.

Choice B Reason:

Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.

Choice C Reason:

Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.

Choice D Reason:

Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.

Choice E Reason:

Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.

Choice A Reason:

Spinal cord injuries can disrupt the autonomic nervous system, impairing the body's ability to regulate temperature (thermoregulation). This can lead to temperature sensitivity, with clients experiencing issues such as difficulty sweating, shivering, or adapting to extreme temperatures.

Choice B Reason:

Contractures, which are the shortening and tightening of muscles, tendons, or ligaments, can occur as a complication of spinal cord injuries. Immobility and spasticity commonly seen in SCI can contribute to the development of contractures.

Choice C Reason:

Sexual dysfunction is a common complication of spinal cord injuries. SCI can affect sexual function and reproductive health due to changes in sensation, mobility, and autonomic nervous system function.

Choice D Reason:

Disc degeneration, or degenerative disc disease, typically occurs as a result of aging and wear and tear on the spinal discs. While SCI may lead to changes in spinal alignment and biomechanics, it is not a direct cause of disc degeneration.

Choice E Reason:

Urinary tract infections (UTIs) are a common complication of spinal cord injuries. Neurogenic bladder dysfunction, which is common in SCI, can lead to urinary retention, incomplete bladder emptying, and urinary stasis, increasing the risk of UTIs.