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 C
Explanation
A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence.
B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition.
C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals.
D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.
Correct Answer is C
Explanation
A. Tonic-clonic seizure. Tonic-clonic seizures involve both muscle stiffness (tonic phase) and jerking movements (clonic phase), but they are not characterized by a sudden loss of muscle tone.
B. Myoclonic seizure. Myoclonic seizures involve brief, sudden jerks or twitches of a muscle or group of muscles, not the sudden loss of muscle tone.
C. Atonic seizure. Atonic seizures, also known as "drop attacks," are characterized by a sudden loss of muscle tone, which causes the person to collapse or fall to the ground. This is the correct description of the type of seizure being asked about.
D. Absence seizure. Absence seizures involve brief episodes of staring and loss of awareness but do not cause loss of muscle tone or collapsing.
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