A client admitted 3 days prior with an injury to the thoracic area of this spinal cord tells the nurse, "I'm getting worse. It's harder to breathe.". Which of the following does this information suggest to the nurse?
1. The client is developing pneumonia.
2. The client has atelectasis.
3. The extent of injury cannot yet be determined.
4. The client is actually improving.
3. The extent of injury cannot yet be determined.
Rationale:
With a spinal cord injury, there is an area of ischemia and edema. Because edema extends from the level of injury for two cord segments above and below the affected level, the extent of injury cannot be determined for up to 1 week. The client's complaint of it being harder to breathe could be evidence that extent of injury is becoming more obvious but will not be totally determined for a few more days. The client's complaint of it being harder to breathe may or may not indicate pneumonia or atelectasis. The complaint is not evidence that the client is improving.
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