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 C

Explanation

A. People who abstain from alcohol: Abstaining from alcohol does not necessarily increase the risk of sustaining a traumatic brain injury (TBI). In fact, excessive alcohol consumption can increase the risk of falls and accidents leading to TBIs, but abstaining from alcohol itself is not a risk factor for TBI.

B. People who live in rural areas: Living in rural areas may be associated with certain risk factors for TBIs, such as increased rates of motor vehicle accidents due to factors like higher speed limits and longer distances traveled. However, it is not a direct cause of TBIs.

C. People who play contact sports: Engaging in contact sports, such as football, soccer, or rugby, poses a higher risk of sustaining a traumatic brain injury due to the potential for collisions, falls, and impacts during gameplay.

D. People who are in their 30's: While traumatic brain injuries can occur at any age, individuals who are involved in activities with a higher risk of head injuries, such as contact sports or high-risk occupations, may be more prone to TBIs regardless of their age. Age alone is not a significant risk factor for TBIs.

A. "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor." B. "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." C. "Vision changes occur when the cloudy lens alters the passage of light through the eye." D. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye."

Correct Answer is C

Explanation

A) "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor." This statement describes a mechanism associated with glaucoma, not cataracts. In cataracts, vision changes occur due to the opacity or cloudiness of the lens, not changes in intraocular pressure.

B) "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina." This statement describes a mechanism associated with retinal diseases like diabetic retinopathy, not cataracts. In cataracts, the lens becomes cloudy, affecting the passage of light through the eye.

C) "Vision changes occur when the cloudy lens alters the passage of light through the eye." This statement is correct. Cataracts cause the lens of the eye to become cloudy, which interferes with the passage of light through the eye. This results in vision changes such as blurred vision, glare, and difficulty seeing in low light conditions.

D) "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." This statement describes a mechanism associated with retinal detachment, not cataracts. In cataracts, the lens becomes opaque, but the retinal tissue remains intact.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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