Examkin

Question

Difficulty: EasyPhysiological Adaptation

A nurse is assessing a client who sustained a cervical spinal cord injury earlier in the day. The nurse should recognize which of the following assessment findings as physiological manifestations of neurogenic shock? Select all that apply.

  1. Heart rate of 54 beats per minuteAnswer
  2. Blood pressure of 84/48 mm HgAnswer
  3. Warm, flushed skinAnswer
  4. D
    Heart rate of 122 beats per minute
  5. E
    Cool, clammy skin

Answer

The correct findings are a heart rate of 54 beats per minute, a blood pressure of 84/48 mm Hg, and warm, flushed skin.
Neurogenic shock occurs when a spinal cord injury above T6 disrupts the sympathetic nervous system. The resulting loss of sympathetic tone causes massive peripheral vasodilation and an unopposed parasympathetic response. This unique physiological adaptation presents classically with hypotension, bradycardia, and warm, flushed skin.

Step-by-Step Solution

1
Analyze the client's clinical condition and the nature of the injury.
The client has a cervical spinal cord injury, which places them at high risk for neurogenic shock.
Spinal cord injuries above T6 can disrupt the sympathetic nervous system pathways.
2
Identify the physiological mechanisms of neurogenic shock.
Loss of sympathetic tone leads to unopposed parasympathetic activity, causing massive vasodilation, pooling of blood, and decreased cardiac output.
Understanding the pathophysiology is necessary to anticipate the expected clinical signs.
3
Correlate the pathophysiology with vital sign changes and physical findings.
Vasodilation causes hypotension and warm skin, while unopposed parasympathetic tone causes bradycardia.
This differentiates neurogenic shock from hypovolemic shock, which typically presents with tachycardia and cool, clammy skin.

Key Concept

Neurogenic shock is a distributive shock caused by the loss of sympathetic nervous system tone following a high spinal cord injury, classically presenting with hypotension, bradycardia, and warm, flushed skin.
Estimated Time:1m 0s
Rate this question

Topics

Physiological Adaptation

More questions from this topic