A nurse is collecting neurologic data on a client who has a neurological injury and notes changes suggestive of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent which of the following conditions?

Tachycardia

Agonal breathing

Chest pain

Brainstem ischemia

Answer and Explanation

The Correct Answer is D

Cushing's Triad is a set of three classic signs associated with increased intracranial pressure (ICP). These signs include hypertension, bradycardia, and irregular respirations. The presence of Cushing's Triad indicates severe brain injury or increased ICP, often leading to brainstem compression.

A. Tachycardia (Option A): Increased intracranial pressure can initially lead to tachycardia as the body attempts to compensate for the changes. However, as ICP continues to rise and brainstem compression occurs, the sympathetic response diminishes, resulting in bradycardia rather than tachycardia. Therefore, Cushing's Triad is not associated with preventing tachycardia.

B. Agonal breathing (Option B): Agonal breathing, characterized by gasping, labored breathing, or irregular breathing patterns, may occur as a result of brainstem dysfunction or damage. Cushing's Triad, indicative of increased ICP and impending brainstem herniation, does not prevent agonal breathing. In fact, irregular respirations are part of Cushing's Triad.

C. Chest pain (Option C): Chest pain may occur due to various cardiac or respiratory conditions and is not directly related to Cushing's Triad or increased intracranial pressure. Therefore, Cushing's Triad does not prevent chest pain.

D. Brainstem ischemia (Option D): Increased intracranial pressure can lead to brainstem compression, compromising blood flow to the brainstem and resulting in brainstem ischemia. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, is a nervous system response indicative of severe brain injury or increased ICP, which can lead to brainstem ischemia if left untreated. Therefore, Cushing's Triad is associated with brainstem ischemia rather than preventing it.

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

Explanation

A. Restlessness: Restlessness is a common behavioral manifestation in clients with Alzheimer's disease. It can be caused by various factors, including confusion, agitation, discomfort, or unmet needs. Restlessness may manifest as pacing, fidgeting, or difficulty sitting still.

B. Aggression: Aggression, including verbal or physical aggression, is a behavioral manifestation that can occur in clients with Alzheimer's disease. Aggression may result from frustration, confusion, fear, or other underlying factors. It can present challenges for both the individual with Alzheimer's and their caregivers.

C. Depression: Depression is a mood disorder that can occur in individuals with Alzheimer's disease. Symptoms of depression may include persistent sadness, feelings of hopelessness, social withdrawal, and loss of interest in previously enjoyed activities. Depression can exacerbate cognitive decline and functional impairment in individuals with Alzheimer's.

D. Hyperactivity: Hyperactivity, characterized by excessive or restless activity, can occur in some individuals with Alzheimer's disease. Hyperactivity may be a manifestation of agitation, anxiety, or other underlying factors. It can present challenges for caregivers and may require interventions to manage.

E. Lethargy: Lethargy, or extreme fatigue and lack of energy, can also occur in individuals with Alzheimer's disease. Lethargy may result from physical and cognitive decline, medication side effects, depression, or other medical conditions. It can contribute to decreased engagement in activities and worsening of cognitive function.

A. Elevated erythrocyte sedimentation rate (ESR) B. Elevated thyroid-stimulating hormone (TSH) C. Elevated brain natriuretic peptide (BNP) D. Elevated C-reactive protein (CRP)

Correct Answer is B

Explanation

A. Elevated erythrocyte sedimentation rate (ESR): Elevated ESR indicates inflammation in the body and is not typically associated with the cause of atrial fibrillation.

B. Elevated thyroid-stimulating hormone (TSH): This is the correct answer. A common cause of atrial fibrillation is hyperthyroidism, which is characterized by an overactive thyroid gland and often presents with elevated TSH levels. Thyroid hormones play a significant role in regulating heart rate and rhythm. Excess thyroid hormone can lead to increased heart rate and irregular heart rhythms, including atrial fibrillation.

C. Elevated brain natriuretic peptide (BNP): Elevated BNP levels are associated with heart failure and may indicate cardiac stress or dysfunction. While heart failure can predispose individuals to atrial fibrillation, elevated BNP levels themselves are not a direct cause of atrial fibrillation.

D. Elevated C-reactive protein (CRP): Elevated CRP levels indicate inflammation in the body and are associated with various cardiovascular diseases. While inflammation can contribute to atrial fibrillation, elevated CRP levels alone are not a direct cause of atrial fibrillation.

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A nurse is collecting neurologic data on a client who has a neurological injury and notes changes suggestive of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating the family of a client who has Alzheimer's disease. The nurse should be sure to communicate that which of the following behavioral manifestations can occur in clients with Alzheimer’s disease? (Select All that Apply.)

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

Explanation

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Correct Answer is B

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