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 C

Explanation

A. It occurs immediately when buttons depressed: The device synchronizes with the R wave and does not deliver the shock immediately.

B. It requires a higher amount of joules than is used in defibrillation: Cardioversion typically requires fewer joules compared to defibrillation.

C. It discharges during ventricular depolarization of the heart: Synchronized cardioversion times the electrical shock with the R wave (ventricular depolarization) to avoid delivering energy during the T wave, which could induce ventricular fibrillation.

D. It is programmed to occur in non-sync mode: Cardioversion must be synchronized; non-sync mode is used in defibrillation.

A. A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Correct Answer is D

Explanation

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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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?

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