Which signs are manifestations of the Cushing triad? Select all that apply.
Bradycardia.
Bradypnea.
Hypertension.
Tachycardia.
Correct Answer : A,B,C
Choice A rationale
Bradycardia (slow heart rate) is one of the key components of Cushing's triad, which indicates increased intracranial pressure and impending herniation.
Choice B rationale
Bradypnea (slow respiratory rate) is another manifestation of Cushing's triad and reflects brainstem compression.
Choice C rationale
Hypertension (high blood pressure) is the third component of Cushing's triad, resulting from the body's attempt to maintain cerebral perfusion.
Choice D rationale
Tachycardia (rapid heart rate) is not a sign of Cushing's triad and is not associated with increased intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging adequate water intake is important for overall health, but it does not directly address the client’s fear of undergoing an EEG. Adequate hydration can ensure better conduction of electrical signals, but it has no bearing on the client's anxiety related to a past electrocution incident. Therefore, it would not be effective in alleviating the client's specific fear regarding the EEG procedure.
Choice B rationale
Distracting the client’s attention from the test may temporarily reduce anxiety, but it does not address the underlying fear. The client’s fear stems from a misunderstanding of the EEG procedure, and distraction will not resolve this. It is more effective to provide factual information to dispel the fear.
Choice C rationale
Informing the client that they will not experience any electrical shock is a crucial step in alleviating their fear. An EEG records brain activity through electrodes placed on the scalp; it does not involve sending electrical currents into the body. Clarifying this fact helps address the root cause of the client’s fear, providing reassurance and reducing anxiety.
Choice D rationale
Informing the client that they will experience only mild electrical shock is incorrect and misleading. An EEG does not deliver any electrical shock to the client. Providing inaccurate information could increase the client’s anxiety and distrust. Proper education about the procedure's safety is essential for alleviating the client’s fear.
Correct Answer is B
Explanation
Choice A rationale
Normal posture involves relaxed and symmetrical positioning of the limbs without any abnormal flexion or extension.
Choice B rationale
Decorticate posturing is characterized by abnormal flexion of the upper extremities at the elbows and wrists, and extension of the lower extremities, often indicating damage to the corticospinal tract.
Choice C rationale
Decerebrate posturing involves extension and outward rotation of both the arms and legs, indicating damage to the brain stem, which is more severe than decorticate posturing.
Choice D rationale
Flaccid posture refers to a complete lack of muscle tone and resistance, often seen in severe cases of neurological damage or after a stroke. .
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