What findings would the nurse expect when caring for a client who is experiencing spinal shock?

Hypotension and a decreased level of consciousness.

Stridor, garbled speech, or inability to clear airway.

Bradycardia and decreased urinary output.

Temporary loss of motor, sensory, reflex, and autonomic function.

Answer and Explanation

The Correct Answer is D

Choice A reason: Hypotension and a decreased level of consciousness can occur in spinal shock due to the disruption of the sympathetic nervous system, but these are not the hallmark features. They are more secondary effects rather than the primary presentation.

Choice B reason: Stridor, garbled speech, or inability to clear the airway are not typical findings in spinal shock. These symptoms are more indicative of airway obstruction or respiratory distress, which are not directly related to spinal shock.

Choice C reason: Bradycardia and decreased urinary output can occur in spinal shock due to the loss of sympathetic tone, leading to unopposed parasympathetic activity. While these are relevant symptoms, they do not encompass the full scope of spinal shock.

Choice D reason: The primary findings in spinal shock are the temporary loss of motor, sensory, reflex, and autonomic function below the level of the spinal injury. This includes flaccid paralysis, loss of reflexes, and autonomic dysfunction, such as hypotension and bradycardia. These symptoms are the most defining characteristics of spinal shock.

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Correct Answer is D

Explanation

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.

A. Immediate return to hemodialysis. B. Immediate removal of the transplanted kidney. C. Antibiotic therapy. D. Increased doses of immunosuppressive drugs.

Correct Answer is C

Explanation

Choice A reason: Immediate return to hemodialysis is not typically the first line of treatment for these symptoms. Hemodialysis is a renal replacement therapy used when the kidneys are not functioning adequately. While it may be necessary in some cases, the symptoms described suggest an infection rather than complete kidney failure.

Choice B reason: Immediate removal of the transplanted kidney is a drastic measure and is not the first step in managing these symptoms. This action would be considered only if there is clear evidence of irreversible graft failure or severe complications that cannot be managed with other treatments.

Choice C reason: Antibiotic therapy is

The correct answer. The symptoms of oliguria (low urine output), elevated temperature, increased blood pressure, and signs of fluid retention suggest an infection, which is a common complication after kidney transplantation due to the immunosuppressive medications that lower the immune system's ability to fight infections. Treating the infection with antibiotics is crucial to prevent further complications and preserve the function of the transplanted kidney.

Choice D reason: Increased doses of immunosuppressive drugs are not appropriate in this situation. While immunosuppressive drugs are essential to prevent organ rejection, increasing their dosage in the presence of an infection could further compromise the immune system and exacerbate the infection. The priority is to address the infection first.

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What findings would the nurse expect when caring for a client who is experiencing spinal shock?

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Naxlex Comprehensive Predictor Exams

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

Correct Answer is D

Explanation

What does the nurse expect the healthcare provider to prescribe when a post-kidney transplant client develops oliguria, elevated temperature of 37.8°C, increased blood pressure, and signs of fluid retention 12 days after the surgery?

Correct Answer is C

Explanation

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