A nurse is caring for a client who has a sustained intracranial pressure (ICP) reading of 35 mm Hg. Which of the following findings indicate that the client is experiencing Cushing’s triad? (Select all that apply)

Choice A reason: Slurred speech is not part of Cushing’s triad, which includes hypertension, bradycardia, and irregular breathing due to increased intracranial pressure. Slurred speech may indicate neurological deficits from brain injury or stroke but does not specifically reflect the autonomic response to elevated ICP characteristic of Cushing’s triad.

Choice B reason: A decrease in heart rate (bradycardia) is a component of Cushing’s triad in sustained intracranial pressure (35 mm Hg). Elevated ICP compresses the brainstem, stimulating vagal tone, slowing the heart rate as a compensatory response to maintain cerebral perfusion against rising intracranial pressure.

Choice C reason: Irregular breathing patterns are part of Cushing’s triad in elevated intracranial pressure. Brainstem compression from high ICP (35 mm Hg) disrupts the respiratory control center, causing erratic or Cheyne-Stokes breathing. This reflects severe neurological compromise, signaling the need for urgent ICP management.

Choice D reason: Neck stiffness is associated with meningitis or subarachnoid hemorrhage, not Cushing’s triad. The triad (hypertension, bradycardia, irregular breathing) results from brainstem compression in elevated ICP. Neck stiffness does not reflect the autonomic or respiratory changes specific to this critical response to intracranial pressure elevation.

Choice E reason: Hypertension is a key component of Cushing’s triad in sustained intracranial pressure (35 mm Hg). Elevated ICP triggers a sympathetic response, increasing blood pressure to maintain cerebral perfusion pressure against brain compression, indicating a critical state requiring immediate intervention to reduce intracranial pressure.

Choice A reason: A severe headache, vomiting, seizure, unresponsiveness, and vital signs showing hypertension (205/110 mm Hg), bradycardia (pulse 52/min), and irregular breathing suggest a hemorrhagic stroke. These indicate Cushing’s triad from increased intracranial pressure due to intracranial bleeding, causing brainstem compression and neurological deterioration, requiring urgent intervention.

Choice B reason: Transient ischemic attack (TIA) involves temporary neurological deficits without permanent damage, resolving within hours. Severe headache, seizure, unresponsiveness, and Cushing’s triad (hypertension, bradycardia) are inconsistent with TIA. These symptoms point to a more severe event, like hemorrhagic stroke, with significant intracranial pressure elevation.

Choice C reason: Embolic stroke, caused by a clot blocking a cerebral artery, typically presents with focal deficits like hemiparesis, not severe headache, seizure, or unresponsiveness with Cushing’s triad. These symptoms suggest a hemorrhagic stroke, where bleeding causes rapid intracranial pressure increase, leading to brainstem compression and autonomic changes.

Choice D reason: Thrombotic stroke involves gradual clot formation in a cerebral artery, causing focal neurological deficits like weakness or speech issues. Severe headache, seizure, unresponsiveness, and Cushing’s triad (hypertension, bradycardia) are more indicative of hemorrhagic stroke, where bleeding rapidly elevates intracranial pressure, leading to life-threatening neurological compromise.