A nurse is assessing a client who is experiencing Cushing's triad due to increased intracranial pressure. Which of the following findings should the nurse expect?
Severe hypertension
Narrowed pulse pressure
Diastolic murmur
Increased heart rate
The Correct Answer is A
A. Severe hypertension: Cushing’s triad is characterized by increased systolic blood pressure with widening pulse pressure as a compensatory response to maintain cerebral perfusion during increased intracranial pressure. Severe hypertension is a hallmark finding.
B. Narrowed pulse pressure: In Cushing’s triad, the pulse pressure is typically widened, not narrowed, due to elevated systolic pressure and relatively lower diastolic pressure. Narrowed pulse pressure does not reflect the classic pattern associated with increased ICP.
C. Diastolic murmur: A diastolic murmur is a cardiac finding unrelated to increased intracranial pressure and is not a component of Cushing’s triad. It does not provide information about cerebral perfusion or ICP.
D. Increased heart rate: Cushing’s triad involves bradycardia rather than tachycardia, as part of the body’s compensatory response to elevated ICP. An increased heart rate is inconsistent with this classic presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Remove the surgical dressing and obtain a culture: Removing the dressing immediately is unnecessary for routine serosanguineous drainage, which is a normal finding in the early postoperative period. Cultures are only indicated if there are signs of infection such as purulent drainage, redness, or odor.
B. Irrigate the incision with saline: Irrigation is not required for normal serosanguineous drainage and may disrupt the healing process. It is reserved for wounds with debris, infection, or specific provider orders.
C. Clean the wound with hydrogen peroxide: Hydrogen peroxide can damage healthy tissue and delay healing. It is not indicated for routine postoperative care and should be avoided for normal drainage.
D. Mark the outline of the drainage: Marking the outline of the drainage allows the nurse to monitor for changes in amount and size over time. Tracking progression helps identify potential complications such as excessive bleeding or infection and supports timely interventions.
Correct Answer is A
Explanation
A. "You should increase your daily fluid intake.": Adequate hydration is important during early pregnancy to support maternal blood volume expansion, amniotic fluid production, and overall health. Increasing fluid intake can also help alleviate common symptoms such as constipation and mild nausea.
B. "Headaches are expected throughout pregnancy.": While mild headaches can occur, persistent or severe headaches are not considered normal and may indicate complications such as hypertension. Clients should be advised to report significant or recurrent headaches to their provider.
C. "You will feel your baby moving within the next month.": Fetal movement, or “quickening,” typically occurs between 16–20 weeks of gestation for primigravid clients, not at 9–10 weeks. Early reassurance should focus on expected developmental milestones for this stage.
D. "Hormone shifts often cause severe vomiting.": Mild nausea and vomiting are common in early pregnancy due to hormonal changes, but severe vomiting (hyperemesis gravidarum) is not expected and requires medical evaluation for hydration and nutritional management.
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