60. Which change in a vital sign should a nurse note that is specific to neurogenic shock in a client who has a spinal cord injury?
60. Which change in a vital sign should a nurse note that is specific to neurogenic shock in a client who has a spinal cord injury?
Test-Taking Tip
Look for opposites: tachycardia (Answer 3) versus bradycardia (Answer 1). Typical vital sign changes with shock include tachycardia, so that it isn't specific to one type of shock as this question asks.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is correct because there is a loss of autonomic nervous system function below the level of injury—pulse decreases, which is unique to spinal cord injury. Answer 2 is incorrect because hypotension is not specific to spinal cord injury. Answer 3 is incorrect because the loss of autonomic nervous system function causes bradycardia. Answer 4 is incorrect because an abrupt onset of fever may occur, but hyperthermia is not specific to neurogenic shock. Fever is present in septic shock.
