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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

A papule is a small, raised, solid pimple or swelling on the skin, often forming part of a rash. It does not typically contain pus and is not associated with impetigo, which is characterized by pustules.

Choice B rationale

A vesicle is a small fluid-filled blister on the skin, usually containing clear fluid. Impetigo typically presents with pustules rather than vesicles.

Choice C rationale

A wheal is a raised, itchy area of skin that is often a sign of an allergic reaction. It is not characteristic of impetigo, which involves pustules.

Choice D rationale

Impetigo is a highly contagious bacterial skin infection that usually presents with pustules, which are raised lesions containing pus. These pustules can rupture and form a yellowish crust, which is a hallmark of impetigo.

A. Oculomotor. B. Vestibulocochlear. C. Facial. D. Trigeminal.

Correct Answer is A

Explanation

Choice A rationale

The oculomotor nerve (cranial nerve III) is responsible for innervating the muscles that move the eye and lift the eyelid, as well as controlling pupil constriction and lens shape for focusing.

Choice B rationale

The vestibulocochlear nerve (cranial nerve VIII) is involved in hearing and balance, not in the movement of eye muscles or eyelids.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression, taste sensations from the anterior two-thirds of the tongue, and functions in tear and saliva production.

Choice D rationale

The trigeminal nerve (cranial nerve V) is responsible for sensation in the face and motor functions such as biting and chewing, not for eye movements.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with impetigo. The nurse would most likely observe which of the following?

Correct Answer is D

Explanation

Which cranial nerve is responsible for muscles that move the eye and lids?

Correct Answer is A

Explanation

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