Question

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for:

A. A flattened abdomen.
B. Hematest positive nasogastric tube drainage.
C. Hyperactive bowel sounds.
D. A history of diarrhea.

Answer 1

When monitoring a client with a spinal cord injury for GI complications, nurses should look for hematest-positive nasogastric tube drainage, as it indicates gastrointestinal bleeding, a critical acute complication.

Step-by-step explanation:

The nurse caring for a client with a spinal cord injury should monitor for gastrointestinal (GI) complications, which can include a range of symptoms due to the potential impact on the autonomic nervous system. One key sign the nurse would assess for is hematast-positive nasogastric tube drainage, which would indicate bleeding in the gastrointestinal tract. A flattened abdomen may not necessarily signal a GI complication, as it does not specifically indicate bleeding or dysfunction. Hyperactive bowel sounds could suggest GI motility issues, but they are not direct indicators of GI bleeding or severe complications. Finally, a history of diarrhea might be relevant to the patient's case but, in itself, is not a primary monitoring factor for acute complications within 48 hours post-injury.