Which assessment finding is a component of Cushing's triad, indicating increased intracranial pressure (ICP)?
Fever
Tachycardia
Bradycardia
Hypotension
The Correct Answer is C
Cushing’s triad is a late manifestation of dangerously elevated intracranial pressure, impaired cerebral perfusion, brainstem compression, and impending neurologic herniation. The classic findings include bradycardia, widened pulse pressure, and irregular respirations resulting from autonomic nervous system responses to severe cerebral ischemia.
Rationale:
A. Fever may occur with infection, hypothalamic dysfunction, or inflammatory processes but is not a defining component of Cushing’s triad. Elevated intracranial pressure primarily produces cardiovascular and respiratory alterations related to brainstem compression. Classic manifestations involve autonomic dysregulation and impaired cerebral circulation rather than temperature elevation alone.
B. Tachycardia is not characteristic of Cushing’s triad and more commonly occurs with hypovolemia, pain, fever, or shock states. Increased intracranial pressure instead stimulates parasympathetic responses producing slowed heart rate. Severe neurologic compromise causes brainstem compression and reflex cardiovascular changes opposite to tachycardic responses.
C. Bradycardia is a classic component of Cushing’s triad associated with dangerously elevated intracranial pressure and reduced cerebral perfusion. Increased pressure compresses brainstem structures, triggering vagal stimulation and slowed cardiac rate. This finding indicates worsening neurologic deterioration and potentially life-threatening intracranial hypertension requiring urgent intervention.
D. Hypotension is inconsistent with Cushing’s triad because increased intracranial pressure typically causes systemic hypertension with widened pulse pressure to preserve cerebral perfusion. Hypotension instead decreases cerebral blood flow and worsens ischemic injury. Cushing’s response involves compensatory arterial hypertension and altered brainstem function during intracranial crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Heterotopic ossification is abnormal bone formation within soft tissues following neurologic injury, causing progressive joint inflammation, restricted range of motion, and periarticular pain. Spinal cord injury commonly predisposes clients to ectopic calcification around major joints due to inflammatory and neurovascular alterations.
Rationale:
A. Arthralgia commonly occurs with heterotopic ossification because abnormal bone deposition around joints produces inflammation, swelling, and restricted movement. Clients frequently experience localized pain and decreased mobility during active ossification phases. Progressive periarticular calcification causes impaired joint mobility and discomfort in affected extremities.
B. Hypertension is more closely associated with autonomic dysreflexia rather than heterotopic ossification after spinal cord injury. Although both complications may occur in neurologically impaired clients, elevated blood pressure is not a characteristic manifestation of ectopic bone formation. Heterotopic ossification primarily affects musculoskeletal function and surrounding soft tissues.
C. Fecal impaction is a gastrointestinal complication associated with neurogenic bowel dysfunction following spinal cord injury rather than heterotopic ossification. Ectopic bone growth specifically affects joints and connective tissues surrounding skeletal structures. Resulting complications mainly involve mobility limitation and impaired musculoskeletal movement rather than bowel elimination problems.
D. Bradycardia commonly develops from autonomic nervous system disruption in high spinal cord injuries but is not directly linked to heterotopic ossification. Abnormal ectopic bone growth primarily produces local inflammatory musculoskeletal manifestations. The condition mainly causes joint stiffness and progressive painful mobility restriction in affected areas.
Correct Answer is C
Explanation
Delirium is an acute neurocognitive disorder characterized by impaired attention, fluctuating consciousness, disrupted sleep–wake cycles, and altered cerebral neurotransmission. It is commonly triggered in hospitalized clients by immobility, infection, sensory deprivation, medications, and environmental disorientation affecting normal brain function.
Rationale:
A. Avoiding family involvement increases sensory deprivation and disorientation, which are major risk factors for delirium. Family presence helps maintain orientation, emotional stability, and cognitive engagement. Reduced social stimulation and impaired environmental orientation contribute to worsening cognitive dysfunction.
B. Frequent use of restraints increases agitation, reduces mobility, and worsens sensory deprivation, all of which significantly increase delirium risk. Restraints are associated with increased confusion and psychological distress. They exacerbate cognitive impairment and reduce environmental interaction, worsening neuropsychiatric outcomes.
C. Early mobility is the most effective intervention for preventing delirium because it improves cerebral perfusion, reduces inflammation, enhances sleep regulation, and decreases sensory deprivation. Mobilization supports cognitive function and physiologic stability. Improved neurologic stimulation and enhanced physiologic recovery reduce delirium incidence in hospitalized clients.
D. Keeping lights on all night disrupts circadian rhythms and sleep–wake cycles, which are critical in maintaining cognitive stability. Sleep deprivation is a major risk factor for delirium development. Continuous light exposure impairs melatonin regulation and worsens circadian rhythm disruption, increasing confusion and agitation.
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