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.
Tachycardia.
Bradypnea.
Hypertension.
Bradycardia.
Correct Answer : B,C,D
Choice A rationale
Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.
Choice B rationale
Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.
Choice C rationale
Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.
Choice D rationale
Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.
Choice E rationale
Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Techniques for performing neck ROM exercises might be relevant but are secondary to the immediate postoperative care following a cervical discectomy.
Choice B rationale
Restoring nerve function is a goal but not directly linked to discharge education strategies after cervical discectomy.
Choice C rationale
Home assessment of ABGs is not relevant to discharge education for a cervical discectomy, as it pertains more to respiratory status monitoring.
Choice D rationale
Care of the cervical collar is essential post-discectomy as it provides stability, reduces strain on the cervical spine, and supports the healing process, making it a critical part of discharge education.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.
Choice B rationale
Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.
Choice C rationale
Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.
Choice D rationale
Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.
Choice E rationale
Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.
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