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 B
Explanation
Choice A rationale
Scoliosis refers to a lateral curvature of the spine, not an exaggeration of the lumbar spine curve, which is characterized by lordosis.
Choice B rationale
Lordosis is an exaggerated inward curve of the lumbar spine, often referred to as swayback. This condition is identified by the nurse as the client presents with an exaggerated lumbar curve.
Choice C rationale
Kyphosis describes an excessive outward curvature of the thoracic spine, resulting in a hunched back, not the lumbar spine.
Choice D rationale
Dowager's hump is a term commonly associated with kyphosis, characterized by a pronounced curvature of the upper back, not the lumbar region.
Correct Answer is A
Explanation
Choice A rationale
Potassium-rich foods, such as bananas and potatoes, are recommended for clients with prolonged diarrhea to replace lost electrolytes and maintain normal cellular function.
Choice B rationale
High-fat foods are not recommended for clients with prolonged diarrhea, as they can exacerbate symptoms and are difficult to digest.
Choice C rationale
High-fiber foods may worsen diarrhea by increasing stool bulk and frequency.
Choice D rationale
While protein-rich foods are important, they do not specifically address the electrolyte imbalances caused by prolonged diarrhea.
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