The nurse is monitoring a 7-year-old child post-surgical resection of a supratentorial (cerebral) brain tumor. Which vital sign finding indicates Cushing's triad?
Increased temperature, tachycardia, tachypnea
Decreased temperature, bradycardia, bradypnea
Bradycardia, high blood pressure, irregular respirations
Bradycardia, hypotension, tachypnea
The Correct Answer is C
A. Increased temperature, tachycardia, tachypnea is not consistent with Cushing's triad. These signs generally reflect an infection, fever, or a stress response, and are not indicative of increased intracranial pressure (ICP) or brain herniation.
B. Decreased temperature, bradycardia, bradypnea is incorrect. While bradycardia is a component of Cushing's triad, decreased temperature and bradypnea are not part of this syndrome. The signs of Cushing's triad typically include increased blood pressure, not decreased temperature.
C. Bradycardia, high blood pressure, irregular respirations is correct. These are the hallmark signs of Cushing's triad, which indicate a significant increase in intracranial pressure. Bradycardia occurs as a result of elevated pressure on the brainstem, high blood pressure develops as a compensatory mechanism to maintain perfusion, and irregular respirations reflect brainstem dysfunction.
D. Bradycardia, hypotension, tachypnea is incorrect. Hypotension is not part of Cushing's triad. Instead, high blood pressure is typically present in this condition due to the body's compensatory response to increased ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Mindfulness meditation techniques are effective strategies for managing stress and improving emotional well-being. These techniques help staff process their feelings and reduce anxiety, allowing for better coping with the emotional demands of caring for terminally ill children.
B. Work extended shifts is not recommended. Long shifts without adequate breaks contribute to burnout and fatigue, which can impair the ability to provide quality care and negatively affect staff well-being.
C. Develop professional support systems is critical. Building a support network with peers, supervisors, or mental health professionals can help staff process difficult emotions and prevent burnout.
D. Take sleep aids at night is not an ideal solution. While sleep is essential for stress management, reliance on sleep aids can lead to dependency and does not address the underlying stress or emotional challenges. Healthy sleep hygiene practices are more beneficial in the long term.
E. Attend funeral services if desired can be a meaningful way for staff to express their grief and provide closure. It also offers an opportunity for emotional support, which is crucial in maintaining emotional health after working with terminally ill children.
Correct Answer is C
Explanation
A. 2-3 months is too early for palatoplasty, as the child’s palate and facial structures need time to develop. Surgical repair of the palate is typically done later, once the child is more developed.
B. 18-24 months is too late for the initial palatoplasty. Early intervention is preferred for speech development and other aspects of the child’s overall growth.
C. 6-12 months is the recommended age range for palatoplasty, as this is the time when the child’s palate has matured enough for surgery, and earlier intervention supports optimal outcomes for speech and facial development.
D. 4-5 years is too late for the first palatoplasty. However, additional surgeries or interventions may be needed during this age range as the child grows and their oral structures continue to develop.
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