A nurse assesses a client who experienced a spinal cord injury at ...

[haleyc112]

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.)
 
  a. Heart rate of 34 beats/min
  b. Blood pressure of 185/65 mm Hg
  c. Urine output less than 30 mL/hr
  d. Decreased level of consciousness
  e. Increased oxygen saturation

Question 2

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.)
 
  a. Apply a barrier cream to protect the skin from excoriation.
  b. Perform range-of-motion (ROM) exercises for the hip joint.
  c. Re-position the client off of the reddened areas.
  d. Get the client out of bed and into a chair once a day.
  e. Obtain a low-air-loss mattress to minimize pressure.

[Cheesycrackers]

Answer to Question 1

ANS: A, C, D
Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

Answer to Question 2

ANS: C, E
Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

[haleyc112]

TYSM

[AmberC1996]

Excellent