The patient is admitted with injuries that were sustained in a fall
During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right side, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are most consistent with which condition? 1. Paraplegia
2. Neurogenic shock
3. High cervical injury
4. Temporary hypovolemia
2
Rationale 1: Paraplegia is paralysis of both lower extremities. This patient has paralysis on the right.
Rationale 2: Findings associated with neurogenic shock include hypotension, bradycardia, peripheral vasodilation, and decreased cardiac output.
Rationale 3: There is no mention of the lack of respiratory effort generally associated with high cervical injury.
Rationale 4: Because the patient is bradycardic, the cause of these findings is more likely to be neurogenic shock than hypovolemic shock.
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