The trauma intensive care nurse suspects a client with a C6 fracture has developed neurogenic shock.
Which findings support the nurse's suspicion?
Hypotension, bradycardia, warm and pink extremities.
Hyperactive reflexes below C6.
Lack of sensation and movement below C6.
Involuntary spastic movement of extremities.
The Correct Answer is A
Evaluating a cervical spine injury for neurogenic shock requires knowledge of autonomic nervous system disruption. Specifically, loss of sympathetic tone below the level of injury must be identified. Differentiating neurogenic shock from spinal shock involves assessing hemodynamic parameters and thermoregulation.
Choice A rationale
Neurogenic shock involves loss of sympathetic vascular tone, causing massive vasodilation and hypotension. Unchecked parasympathetic activity leads to bradycardia. Normal heart rate is 60 to 100. Warm, pink skin results from peripheral blood pooling due to vasodilation.
Choice B rationale
Hyperactive reflexes are characteristic of the later stages of spinal cord injury after spinal shock resolves. They do not indicate the acute hemodynamic collapse seen in neurogenic shock, which specifically targets the cardiovascular regulatory systems.
Choice C rationale
Loss of sensation and movement defines spinal shock or the initial cord injury itself. While present in neurogenic shock, these findings are not specific to the autonomic failure that characterizes the life-threatening hemodynamic instability of shock.
Choice D rationale
Spasticity occurs due to upper motor neuron damage after the initial period of areflexia. This is a chronic or subacute finding and is not associated with the acute cardiovascular distributive failure seen in neurogenic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Accurate neurologic assessment in suspected stroke requires systematic comparison to identify focal deficits. Applying knowledge of neuroanatomy and lateralization of brain function is essential to differentiate between localized ischemic events and generalized systemic issues, ensuring the correct vascular territory is identified.
Choice A rationale
Rapid assessments may lead to overlooking subtle focal neurologic deficits or sensory changes. Precision is required to localize the brain lesion accurately. While time is critical in stroke, haste must not compromise the integrity and detail of the examination.
Choice B rationale
The supine position may increase intracranial pressure or compromise the airway in a stroke patient with decreased gag reflexes. Assessing certain reflexes and motor strength often requires varying the head of the bed to at least 30 degrees for safety.
Choice C rationale
Symmetry is the hallmark of neurologic health. Comparing left and right sides allows the nurse to identify unilateral weakness, sensory loss, or reflex changes characteristic of stroke. This lateralization helps distinguish focal neurological deficits from global brain dysfunction.
Choice D rationale
Anxiolytics can depress the central nervous system, altering the level of consciousness and pupillary responses. This medication masks the client's true neurologic status, making it impossible to obtain a baseline or detect subtle clinical changes or deterioration.
Correct Answer is A
Explanation
Pyloric obstruction involves a mechanical blockage at the stomach outlet, leading to the accumulation of gastric contents. Knowledge of gastrointestinal decompression and the therapeutic purpose of nasogastric tubes in managing increased intragastric pressure and preventing emesis is required here.
Choice A rationale
Pyloric obstruction causes gastric stasis and distension because contents cannot enter the duodenum. Nasogastric intubation provides decompression by removing accumulated secretions and gas, which relieves pressure, prevents vomiting, and reduces the risk of aspiration in the client.
Choice B rationale
Providing nutrition via tube feeding is contraindicated in pyloric obstruction. Because the outlet of the stomach is blocked, any enteral formula introduced would accumulate in the stomach, worsening distension and significantly increasing the risk of reflux or aspiration.
Choice C rationale
While gastric pH can be measured via a nasogastric tube, it is not the primary therapeutic rationale for tube placement in a client with a mechanical obstruction. Decompression is a critical intervention to ensure safety and comfort.
Choice D rationale
Administering oral medications through a nasogastric tube is ineffective during an obstruction. The medication cannot pass the pylorus to be absorbed in the small intestine, and it adds volume to an already overfilled and pressurized stomach.
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