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 A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

A. Inability to see objects on one side of the visual field B. Inability to perform a previously learned action C. Inability to repeat a simple sentence D. Inability to hear from the ear on the affected side

Correct Answer is B

Explanation

A. Inability to see objects on one side of the visual field: This describes hemianopsia, not apraxia.

B. Inability to perform a previously learned action: Apraxia is the loss of the ability to perform skilled movements or gestures despite having the desire and physical ability to do so.

C. Inability to repeat a simple sentence: This describes aphasia, specifically expressive or receptive aphasia.

D. Inability to hear from the ear on the affected side: This describes hearing loss, which is unrelated to apraxia.

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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

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

The nurse is caring for a client with an ischemic stroke who has apraxia. Which of the following deficits would the nurse expect the client to have?

Correct Answer is B

Explanation

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