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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Keep the infant supine is incorrect. After cleft palate repair, it is generally recommended to keep the infant in a position that minimizes pressure on the surgical site. Keeping the infant in a supine position may cause pressure on the repaired area, so side or semi-prone positioning is preferred.

B. Suction the mouth with an oral suction tube is incorrect. Suctioning should be avoided unless absolutely necessary because it can irritate the surgical site and cause trauma to the newly repaired palate.

C. Apply elbow restraints and release them periodically is correct. Elbow restraints are commonly used after cleft palate surgery to prevent the infant from touching or putting pressure on the surgical site. These restraints should be periodically released to allow for movement and prevent skin breakdown.

D. Feed the infant with a spoon for 48 hours is incorrect. After cleft palate repair, feeding should be done carefully. Special feeding bottles or cups are typically used to avoid trauma to the surgical site. Feeding with a spoon may cause pressure on the repair and should be avoided.

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin. B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin. C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin. D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin.

Correct Answer is C

Explanation

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin is incorrect. An inguinal hernia involves a protrusion of bowel or fatty tissue through a weakness in the abdominal wall, not digestive fluids leaking from the bowel.

B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin is incorrect. Inguinal hernias are congenital or result from increased intra-abdominal pressure, not caused by viral infections.

C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin is correct. Inguinal hernias occur when tissue, usually part of the intestine or fatty tissue, pushes through a weak area in the abdominal wall near the groin. This condition is common in infants and children.

D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin is incorrect. While excess gas can cause bloating or discomfort, it is not responsible for the development of an inguinal hernia. The bulge is caused by the protrusion of tissue through a weakness in the abdominal wall.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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