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

Fever is typically regulated by the hypothalamus, a part of the brain that controls body temperature. Dysfunction of the lower brain stem does not typically cause fever.

Choice B rationale

Visual disturbances are often related to issues with the visual cortex or optic pathways, which are not part of the lower brain stem.

Choice C rationale

Gait alteration is typically associated with dysfunction in the cerebellum or motor pathways, rather than the lower brain stem.

Choice D rationale

Hypoxia, or decreased oxygen levels, can be a critical concern with lower brain stem dysfunction as the lower brain stem controls vital autonomic functions such as respiration and heart rate.

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.