Author Question: A patient is admitted with injuries sustained in a fall. During the nurse's first assessment upon ... (Read 140 times)

fagboi · **on:** Jun 25, 2018

A patient is admitted with injuries sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right,

absent bowel sounds, zero urine output, and palpation of a distended bladder. The nurse realizes that these findings are consistent with which condition?

1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia

Question 2

A patient with a spinal cord injury (SCI) has complete paralysis of both upper and lower extremities. Which term should the nurse use when documenting this patient's status?

1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia

hramirez205 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2

Spinal shock is the response of the cord itself to injury. It involves temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord. As a result of the injury, sympathetic function is interrupted and parasympathetic function is unopposed. This condition is characterized by flaccid paralysis, loss of skin reflexes and deep tendon reflexes, and loss of all sensations below the level of injury. There is loss of urinary bladder tone. The autonomic dysfunction results in hypotension. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in a spine-injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

Answer to Question 2

Correct Answer: 4
Quadriplegia is the complete paralysis of the upper extremities and the lower part of the body. Hemiplegia is paralysis on one side of the body, and paraplegia is paralysis of the lower body. Paresthesia does not include paralysis.