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 D

Explanation

Choice A reason: Inspecting peripheral vein distention assesses superficial thrombosis, not deep vein thrombosis (DVT), which occurs in deep veins like the femoral. DVT presents with calf inflammation, not visible vein distention, making this assessment less specific for diagnosing the condition’s classic signs.

Choice B reason: Observing breathing pattern changes detects pulmonary embolism, a DVT complication, not DVT itself. Calf inflammation is a primary DVT sign, and breathing changes are secondary, making this assessment irrelevant for initial DVT evaluation, focusing on systemic rather than localized findings.

Choice C reason: Palpating pedal pulses assesses arterial flow, not venous thrombosis. DVT causes calf inflammation and swelling, not pulse changes, unless severe. This assessment is less relevant, as DVT primarily affects venous return, making calf inflammation the priority for diagnosis.

Choice D reason: Assessing calf inflammation is critical, as DVT causes unilateral swelling, redness, and warmth due to venous obstruction. This classic sign, often with pain, directly indicates thrombus formation, making it the most specific assessment for diagnosing DVT and guiding anticoagulation therapy.

A. Educate client on signs and symptoms of narcotic dependency B. Give maximum dosage when score reaches 10 C. Administer opioid and non-opioid medication simultaneously D. Alternate IV and IM analgesic medications

Correct Answer is C

Explanation

Choice A reason: Educating on narcotic dependency is inappropriate during severe pain (8/10). Stage IV bone cancer requires aggressive pain control, and dependency concerns are secondary. Administering medications relieves suffering, aligning with palliative goals, making education irrelevant at this acute pain crisis moment.

Choice B reason: Waiting for a pain score of 10 delays relief, worsening suffering in stage IV bone cancer. Severe pain (8/10) requires immediate intervention with opioid and non-opioid drugs, as delaying treatment exacerbates distress, making this approach ineffective and contrary to pain management protocols.

Choice C reason: Administering opioid and non-opioid medications simultaneously is optimal, as opioids target nociceptive pain, and non-opioids (e.g., NSAIDs) reduce bone inflammation in stage IV cancer. This multimodal approach maximizes relief for severe pain (8/10), aligning with palliative care guidelines, making it the priority intervention.

Choice D reason: Alternating IV and IM analgesics is inefficient and delays relief. Simultaneous opioid and non-opioid use addresses severe pain (8/10) more effectively, targeting different pain pathways, reducing opioid needs, and improving outcomes, making alternating routes less effective for immediate control.

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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 is evaluating a client for possible deep vein thrombosis (DVT). Which assessment should the nurse perform?

Correct Answer is D

Explanation

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Correct Answer is C

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