A nurse is caring for a client who has been trending with elevated intracranial pressure (ICP) readings for some time. Which of the following findings should the nurse identify as signs indicating Cushing's Triad? (Select all that apply.)

Increased ammonia levels

Irregular breathing pattern

Decreased heart rate

Slurred speech

Positive Kernig's sign

Answer and Explanation

Correct Answer : B,C

A. Increased ammonia levels are associated with hepatic encephalopathy, not increased ICP or Cushing's Triad.
B. It is one of the three classic signs of Cushing's Triad, which indicates late increased ICP and possible brain herniation.
C. Bradycardia is a hallmark sign of Cushing's Triad and reflects brainstem dysfunction due to increased ICP.
D. Slurred speech may occur with increased ICP but is not a component of Cushing's Triad.
E. Positive Kernig's sign indicates meningeal irritation, such as in meningitis, not increased ICP or Cushing's Triad.

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Correct Answer is C

Explanation

A. Hypocalcemia is not a primary concern in DKA treatment.
B. Hyponatremia can occur but is less immediately critical than potassium imbalance.
C. During treatment of DKA, insulin administration drives potassium into cells, potentially causing dangerous hypokalemia, so close monitoring of potassium levels is essential.
D. Hypomagnesemia is less common and not the primary focus during DKA management.

A. Open the airway using a jaw-thrust maneuver. B. Determine effectiveness of ventilator efforts. C. Establish IV access. D. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment.

Correct Answer is ["A","B","C","D","E"]

Explanation

A (Airway): Open the airway using a jaw-thrust maneuver is the first action to ensure the airway is patent, especially important in trauma to avoid cervical spine injury.

B (Breathing): Determine effectiveness of ventilator efforts comes next to assess if the client is ventilating adequately.

C (Circulation): Establish IV access is part of restoring and maintaining circulation, allowing for fluid resuscitation or medication administration.

D (Disability): Perform a Glasgow Coma Scale assessment evaluates neurological function to determine the level of consciousness.

E (Exposure): Remove clothing for a thorough assessment ensures the nurse can identify all injuries and prevent missing any life-threatening conditions.

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A nurse is caring for a client who has been trending with elevated intracranial pressure (ICP) readings for some time. Which of the following findings should the nurse identify as signs indicating Cushing's Triad? (Select all that apply.)

Nursing Test Bank

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