Reference no: EM133843348

Questions

1. After a fall, a patient's vital signs at the accident site are pulse of 40 beats/min, blood pressure of 84/40 mm Hg, respirations of 14/min, and temperature of 95o F. His lower extremities are flaccid, bowel sounds are absent, and the bladder is distended. The patient is exhibiting:

a. Tetraplegia
b. Spinal shock
c. Autonomic dysreflexia
d. Brown-Séquard's syndrome

2. Spinal cord injury can be complicated by hypotension and bradycardia. These manifestations are primarily a result of:

a. Massive vasoconstriction in response to increased sympathetic input
b. Loss of sympathetic function and increased venous capacity
c. Release of proteolytic enzymes that clog microcirculation
d. Internal bleeding with associated hypovolemic shock

3. A young man is admitted with a spinal cord injury at T1. Which nursing diagnosis is appropriate with regard to respiratory function?

a. Impaired gas exchange related to paralysis of intercostal muscles
b. Ineffective airway clearance related to loss of accessory muscles
c. Ineffective breathing related to paralysis of the phrenic nerve
d. Ineffective breathing related to paralysis of the diaphragm

4. The nurse writes a diagnosis of impaired elimination for the patient with a spinal cord injury. An essential item of data to know during the planning stage is the:

a. Patient's understanding of the injury
b. Level at which the spinal cord is injured
c. Patient's tendency to develop poikilothermia
d. Type of mechanical injury inflicted on the spinal cord