A nurse caring for a client with head trauma will be monitoring the client for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Choice A rationale

Infection is not directly related to weight loss, ill-fitting dentures, or limited fiber intake. The primary risks are more connected to gastrointestinal function rather than infections. While malnutrition can affect immune response, infection risk isn’t the primary concern here.

Choice B rationale

Deficient fluid volume is not a direct consequence of weight loss or dietary habits related to ill-fitting dentures. While fluid intake should be monitored, it is not the most immediate risk associated with these symptoms.

Choice C rationale

Excessive intake of convenience foods might contribute to poor nutritional status and unintended weight loss, but it is not the primary risk. The client's condition more directly influences gastrointestinal health rather than dietary habits.

Choice D rationale

Constipation is a significant risk due to limited intake of high-fiber foods. Fiber is crucial for promoting bowel movements and preventing constipation. Weight loss and ill-fitting dentures may further reduce the client's dietary fiber intake, increasing the likelihood of constipation

Choice A rationale

Scales represent the accumulation of dead skin cells that flake off, a common secondary lesion in eczema resulting from the chronic inflammation and rapid skin cell turnover.

Choice B rationale

Erosion occurs when the superficial layer of skin is lost, typically due to scratching or friction in eczema, exposing the underlying epidermis and sometimes leading to infection.

Choice C rationale

Crusts form when serum, blood, or purulent exudate dries on the skin surface, often seen in eczema as a result of weeping lesions and subsequent drying.

Choice D rationale

Ulcers are deeper lesions extending into the dermis or subcutaneous tissue and are not typically associated with eczema. Eczema usually affects the epidermis, causing secondary lesions like scales, erosion, and crusts rather than deep tissue ulcers.