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Chapter 23: Problem 123

The nurse is caring for a client in the ER with a spinal cord injury at T4. Assessment reveals a BP of \(76 / 48\), heart rate of 52 , and no reflex activity below the T4 area. The nurse should further assess the client for which of the following complications? A. Neurogenic shock B. Autonomic dysreflexia C. Meningitis D. Increased intracranial pressure

Short Answer

Expert verified
Answer: A. Neurogenic shock

Step by step solution

01

Analyze the given symptoms

The client has spinal cord injury at T4, assessment reveals BP of 76/48 (which is quite low), heart rate of 52 (low), and no reflex activity below the T4 area.
02

Understand the complications

Here's a brief overview of the complications mentioned: A. Neurogenic shock: A type of shock that occurs after a spinal cord injury, causing low BP and bradycardia (slow heart rate). B. Autonomic dysreflexia: A potentially life-threatening condition due to spinal cord injury, usually caused by a problem with the urinary or bowel system. Symptoms include sudden high BP and heart rate. C. Meningitis: Infection and inflammation of the membranes surrounding the brain and spinal cord. Symptoms typically include fever, headache, and neck stiffness. D. Increased intracranial pressure: Abnormal increase in pressure inside the skull. Symptoms may include headache, vomiting, and altered consciousness.
03

Compare symptoms and complications

Given the client's symptoms of low BP, low heart rate, and no reflex activity below the T4 area, it's more likely that the complication is related to Neurogenic shock. Autonomic dysreflexia presents with sudden high BP and heart rate, while meningitis and increased intracranial pressure have symptoms not mentioned in the exercise.
04

Identifying the complication

Based on the analysis and comparison of the symptoms and complications, the nurse should further assess the client for: A. Neurogenic shock

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