A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad.
The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?
Brainstem ischemia
Tachycardia
Agonal breathing
Chest pain
The Correct Answer is A
Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale
While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Vasogenic cerebral edema is the most common type of cerebral edema associated with stroke. It involves swelling outside of brain cells, and leaky blood vessels cause it.
Choice B rationale
Osmotic cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like diabetes-related ketoacidosis and hyponatremia.
Choice C rationale
Cellular, or cytotoxic, cerebral edema can occur due to traumatic brain injury and stroke. However, it is not the most common type of cerebral edema associated with stroke.
Choice D rationale
Interstitial cerebral edema is not typically associated with stroke. It is more commonly seen in conditions like hydrocephalus and meningitis.
Correct Answer is A
Explanation
Choice A rationale
The aura phase is characterized by sensory, motor, or visual disturbances that occur before the headache phase of a migraine. Symptoms such as tingling of the face and blind spots in the eyes are common during this phase.
Choice B rationale
The postdrome phase, also known as the “migraine hangover,” occurs after the headache phase. It does not typically include symptoms such as tingling of the face or blind spots in the eyes.
Choice C rationale
The prodrome phase, also known as the pre-headache phase, can occur hours to days before the headache phase. It can include symptoms such as mood changes, food cravings, and neck stiffness, but not typically tingling of the face or blind spots in the eyes.
Choice D rationale
The headache phase is the period during a migraine when the actual headache occurs. It is not typically associated with symptoms such as tingling of the face or blind spots in the eyes.
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