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. A client who has recently traveled to a underdeveloped country B. A client who eats raw shellfish C. A client who works in a child care center D. A client who has multiple tattoos

Correct Answer is D

Explanation

A. Traveling to an underdeveloped country is more commonly associated with risk for hepatitis A and E due to contaminated food or water, not hepatitis C.
B. Eating raw shellfish is a risk factor for hepatitis A, not hepatitis C.
C. Working in a child care center may increase risk for hepatitis A through fecal-oral transmission, but not hepatitis C.
D. Hepatitis C is primarily transmitted through blood-to-blood contact, and having multiple tattoos, especially if done with non-sterile equipment, increases the risk for hepatitis C infection.

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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.)

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