What is one of the clinical signs a nurse might find when assessing a patient in spinal shock?

In spinal shock, one of the hallmark clinical signs is flaccid paralysis. This condition occurs following a spinal cord injury and is characterized by the loss of motor function and muscle tone below the level of the injury. In the immediate aftermath of the injury, the affected muscles become weak and limp, indicating the disruption of neural pathways that normally control muscle contraction and tone.

Flaccid paralysis is significant because it reflects not only the loss of voluntary movement but also affects reflexes—the absence of muscle tone means that there will be no resistance to passive movements, which can be a critical assessment finding for healthcare providers. This sign assists in determining the level and severity of the spinal injury and guides the subsequent management and rehabilitation strategies.

In contrast, the other options reflect findings that are not typical in the context of spinal shock. Increased heart rate and elevated blood pressure are often associated with autonomic dysregulation, which may occur after the initial phase of spinal shock resolves. Cyanosis indicates a lack of oxygenation and is not a direct consequence of spinal shock itself, as it pertains more to respiratory or circulatory issues.