The nurse is caring for a client with Cushing's triad. The nurse expects the client to have:
Irregular respirations, bradycardia, and widening pressure
Hypotension, jugular venous distention, and mufled heart sound
Fixed pupils, hypertension, and bradycardia
Bradycardia, hypotension, and bradypnea
The Correct Answer is C
Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.
Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.
Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),
hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.
Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.
Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.
Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.
Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.
Correct Answer is B
Explanation
Choice A rationale: Adenomas are benign tumors that originate from glandular tissue, such as the endometrium, the inner lining of the uterus.
Choice B rationale: Leiomyomas, also known as fibroids, are benign tumors that arise from the smooth muscle cells of the myometrium, the middle layer of the uterine wall. They are the most common type of uterine tumors, affecting up to 80% of women by age 50. They can cause symptoms such as heavy menstrual bleeding, pelvic pain, pressure, and infertility.
Choice C rationale: Endometriosis is a condition where endometrial tissue grows outside the uterus, causing inflammation and pain.
Choice D rationale: Adenomyosis is a condition where endometrial tissue invades the myometrium, causing enlargement and distortion of the uterus.
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