ATI MEDSURG 2 NUR 265/ DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE QUESTIONS & ANSWERS 2024

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1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.) A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord.

Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles.

Hyperthermia is incorrect. The nurse should monitor the client for hypothermia caused by a lack of lack of sympathetic input.

Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus.

Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

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Author	ProfoundTutor
Published	30 Jul 2024
Included files	PDF
ATI PN ATI 2024 ATI ATI RN ATI MED SURG ATI Comprehensive Proctored Exam Practice Exam Study Guide Study Guide 2024