A client with suspected increased intracranial pressure (ICP) exhibits clinical manifestations of Cushing’s triad. Which assessment finding would the nurse expect to observe?

Profuse diaphoresis and severe, pounding headache

Reports of chest pain and shortness of breath

Hypotension and venous pooling in the extremities

Pain and a burning sensation upon urination and hematuria

Answer and Explanation

The Correct Answer is C

Choice A reason: Profuse diaphoresis and headache are non-specific and not part of Cushing’s triad (bradycardia, irregular respirations, widened pulse pressure). Increased ICP causes specific cardiovascular and respiratory changes, and these symptoms are more aligned with autonomic dysfunction, making this finding incorrect for Cushing’s triad.

Choice B reason: Chest pain and shortness of breath suggest cardiopulmonary issues, not Cushing’s triad, which reflects increased ICP via bradycardia, irregular breathing, and widened pulse pressure. These symptoms are unrelated to intracranial dynamics, making this finding irrelevant for the expected manifestations of ICP.

Choice C reason: Hypotension is incorrect; Cushing’s triad includes hypertension, not hypotension, with bradycardia and irregular respirations due to ICP compressing brainstem centers. Venous pooling is unrelated, and this choice misrepresents the triad, but it is listed as the answer in error, as hypertension is expected.

Choice D reason: Painful urination and hematuria indicate urinary tract issues, not increased ICP or Cushing’s triad. The triad involves neurological and cardiovascular signs (hypertension, bradycardia, irregular breathing), and urinary symptoms are irrelevant, making this finding incorrect for ICP-related manifestations.

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Correct Answer is B

Explanation

Choice A reason: Palpable cervical lymph nodes suggest infection or malignancy, not stroke risk. Stroke is linked to vascular issues like carotid stenosis, detected by bruit. Lymph nodes are unrelated to cerebrovascular pathology, making this finding irrelevant for identifying stroke risk in the client.

Choice B reason: Carotid bruit indicates turbulent flow from stenosis, a major stroke risk due to potential embolism or reduced cerebral perfusion. This vascular finding directly correlates with ischemic stroke, making it the most critical assessment to report for stroke prevention and evaluation.

Choice C reason: Nuchal rigidity suggests meningitis or subarachnoid hemorrhage, not ischemic stroke risk. Carotid bruit is a specific precursor to embolic stroke, and nuchal rigidity addresses different neurological conditions, making this finding less relevant for stroke risk assessment.

Choice D reason: Jugular vein distention indicates heart failure or venous pressure, not arterial stroke risk. Carotid bruit directly relates to cerebrovascular disease, a stroke precursor, making jugular distention irrelevant, as it reflects cardiovascular, not cerebrovascular, pathology in stroke risk evaluation.

A. Amylase B. Glucose C. Serum triglycerides D. Calcium E. White blood cell count

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Amylase is elevated in acute pancreatitis due to pancreatic acinar cell damage, releasing digestive enzymes. Monitoring serum amylase confirms the diagnosis and tracks disease severity, as levels correlate with inflammation. This is a key marker, essential for assessing pancreatic injury in sudden abdominal pain.

Choice B reason: Glucose levels rise in pancreatitis due to impaired insulin release from damaged pancreatic beta cells. Hyperglycemia indicates disease severity and complications like pancreatic necrosis. Monitoring glucose ensures timely management of metabolic disturbances, critical in acute pancreatitis with sudden pain and systemic effects.

Choice C reason: Serum triglycerides are monitored, as hypertriglyceridemia is a common cause of acute pancreatitis. Elevated levels exacerbate pancreatic inflammation by inducing lipotoxicity. Tracking triglycerides guides treatment, like lipid-lowering therapy, and assesses risk of recurrent attacks, making it essential in suspected pancreatitis cases.

Choice D reason: Calcium levels drop in acute pancreatitis due to fat necrosis binding calcium (saponification). Hypocalcemia signals severe disease and complications like tetany. Monitoring calcium ensures timely supplementation, preventing life-threatening outcomes, and is critical for managing systemic effects in acute pancreatic inflammation.

Choice E reason: White blood cell count rises in pancreatitis due to systemic inflammatory response. Leukocytosis indicates infection or severe inflammation, guiding antibiotic or supportive care needs. Monitoring this assesses disease progression and complications, making it vital for managing suspected acute pancreatitis with abdominal pain.

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A client with suspected increased intracranial pressure (ICP) exhibits clinical manifestations of Cushing’s triad. Which assessment finding would the nurse expect to observe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reports that a client is at risk for a stroke based on which assessment finding?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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