A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

BP 170/64 pulse 58

BP 180/90, pulse 96

BP 110/70, pulse 100

BP 100/60, pulse 54

Answer and Explanation

The Correct Answer is A

A. BP 170/64, pulse 58: Cushing's triad includes increased systolic blood pressure with widened pulse pressure, bradycardia, and irregular respirations, indicating increased intracranial pressure.

B. BP 180/90, pulse 96: Hypertension is present, but the elevated pulse does not align with bradycardia seen in Cushing's triad.

C. BP 110/70, pulse 100: These values do not reflect the classic signs of Cushing's triad.

D. BP 100/60, pulse 54: While bradycardia is present, hypotension does not align with Cushing’s triad.

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Correct Answer is D

Explanation

A. Able to localize pain: A score of 6 is too low for a client to localize pain, which would require higher motor function.

B. Is verbally responsive, but confused: Verbal responsiveness would require a higher score, as a GCS of 6 indicates severe impairment.

C. Moves arms as directed: Following commands is consistent with a higher GCS score.

D. Opens eyes to deep pain only: This response aligns with the minimal responsiveness expected for a GCS score of 6.

A. Auscultate for a pericardial friction rub B. Inspect the skin for petechia C. Palpate the radial pulses bilaterally D. Assess for abdominal pain

Correct Answer is A

Explanation

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

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A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

Nursing Test Bank

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