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 B

Explanation

A. Checking pedal pulses assesses circulation but will not help identify the cause of muscle spasms in this context.
B. Muscle spasms following a thyroidectomy may indicate hypocalcemia, a common complication due to accidental removal or damage to the parathyroid glands during surgery. This electrolyte imbalance can lead to neuromuscular excitability and tetany, which requires prompt recognition and treatment.
C. Requesting a relaxant may mask symptoms without addressing the underlying cause, delaying appropriate treatment.
D. Administering potassium is not appropriate unless hypokalemia is confirmed; muscle spasms in this scenario are more likely due to low calcium, not potassium.

A. Fluid resuscitation B. Fluid restriction C. Administer desmopressin D. Sodium restriction

Correct Answer is B

Explanation

A. Fluid resuscitation is not appropriate for SIADH, where the issue is fluid retention, not loss.
B. Fluid restriction. SIADH causes excess release of antidiuretic hormone, leading to water retention and dilutional hyponatremia. Restricting fluids helps to correct the sodium imbalance.
C. Desmopressin is an ADH analog and is used in diabetes insipidus, not SIADH.
D. Sodium restriction would worsen hyponatremia in SIADH and is contraindicated.

View Question and Answer

A nurse is caring for a client who is admitted to the emergency department for fatigue.

Exhibits

Which 4 findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

View Question and Answer

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following interventions should the nurse implement?

Correct Answer is B

Explanation

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A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which 4 findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

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