A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications?

Choice A rationale A weakened gag reflex is typically associated with injuries to the cranial nerves or brainstem, or very high cervical injuries involving C1 to C3 affecting the glossopharyngeal and vagus nerves. While cervical injuries are serious, the most immediate systemic complications in the emergency phase focus on autonomic stability. Unless the injury is at the highest cervical levels, the gag reflex may remain intact while other life threatening hemodynamic changes occur. Choice B rationale Paralytic ileus is a common complication of acute spinal cord injury due to the disruption of the autonomic nervous system. The sudden loss of sympathetic input leads to a temporary cessation of intestinal peristalsis. Monitoring for the absence of bowel sounds is essential to identify this gastric stasis, which can lead to abdominal distention, vomiting, and aspiration. Bowel sounds should be assessed in all four quadrants regularly during the acute phase. Choice C rationale Polyuria is not a standard finding in acute spinal cord injury. Instead, patients often experience urinary retention due to the loss of autonomic control over the detrusor muscle and external sphincter, leading to a neurogenic bladder. While fluid resuscitation might increase output, the pathology of the injury itself does not trigger excessive urine production. Normal urine output should be maintained at 0.5 mL per kg per hr to ensure renal perfusion. Choice D rationale Patients with cervical spinal cord injuries often experience poikilothermia, where the body temperature adjusts to the environment due to the loss of hypothalamic control and inability to sweat or shiver below the level of the lesion. This usually results in hypothermia rather than hyperthermia, especially in emergency settings. The nurse must monitor core temperature closely because the patient cannot physiologically thermoregulate against ambient temperature shifts in the clinical environment. Choice E rationale Hypotension is a hallmark of neurogenic shock, occurring when a cervical injury causes the loss of sympathetic tone. This results in massive vasodilation and a decrease in systemic vascular resistance. Unlike hypovolemic shock, this hypotension is often accompanied by bradycardia. Maintaining a mean arterial pressure of 85 to 90 mmHg for the first week after injury is often targeted to ensure adequate perfusion to the spinal cord.