Which three symptoms are characteristic of Cushing triad associated with increased ICP?
Bradycardia, hypertension, and widening pulse pressure
Widening pulse pressure, headache, and seizure
Hypertension, tachycardia, and headache
Hypotension, tachycardia, and narrowing pulse pressure
The Correct Answer is A
A. Bradycardia, hypertension, and widening pulse pressure
This combination of symptoms is characteristic of Cushing's triad. Bradycardia (slow heart rate), hypertension (elevated blood pressure), and widening pulse pressure (difference between systolic and diastolic blood pressure) are indicative of increased ICP, specifically resulting in the compression of brain structures that regulate vital functions.
B. Widening pulse pressure, headache, and seizure
While headache and seizure may occur in patients with increased ICP, widening pulse pressure alone is not sufficient to meet the criteria of Cushing's triad. The presence of bradycardia and hypertension, along with widening pulse pressure, is more indicative of Cushing's triad.
C. Hypertension, tachycardia, and headache
Hypertension and headache may occur in patients with increased ICP, but the absence of bradycardia and widening pulse pressure makes this option less characteristic of Cushing's triad.
D. Hypotension, tachycardia, and narrowing pulse pressure
Hypotension (low blood pressure) and narrowing pulse pressure are not typically associated with Cushing's triad. Tachycardia (rapid heart rate) may occur in response to increased ICP, but it is usually accompanied by bradycardia rather than hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Perform passive range of motion on each extremity:
While passive range of motion exercises are important for preventing contractures and maintaining joint mobility in immobilized clients, they are not the highest priority in this situation. Airway management takes precedence over mobility exercises.
B. Monitor the client's electrolyte levels:
Monitoring electrolyte levels is important for overall assessment and management of the client's health, but it is not the highest priority when the client's airway and breathing are compromised.
C. Suction saliva from the client's mouth:
This is the correct answer. Suctioning saliva from the client's mouth helps maintain a clear airway and prevents aspiration. Unconscious clients are at risk for pooling of oral secretions, which can obstruct the airway and lead to respiratory complications.
D. Record the client's intake and output:
While monitoring intake and output is an essential part of nursing care, it is not the highest priority when the client's airway and breathing are compromised.
Correct Answer is C
Explanation
A. Check the client for a fecal impaction.
This intervention is important for managing autonomic dysreflexia because a fecal impaction can trigger autonomic dysreflexia by causing rectal distention. However, it is not the first action the nurse should take. Promptly addressing the immediate cause of autonomic dysreflexia is crucial to prevent complications.
B. Ensure the room temperature is warm.
This intervention is important for maintaining the client's comfort and preventing temperature-related complications. However, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Immediate interventions to address the underlying cause of autonomic dysreflexia are necessary to prevent serious complications such as stroke or seizure.
C. Check the client's bladder for distention.
This is the correct action to take first. Bladder distention is one of the most common triggers of autonomic dysreflexia in individuals with spinal cord injuries. A distended bladder stimulates autonomic reflexes, leading to a sudden increase in blood pressure. Therefore, the nurse should assess the client's bladder for distention and initiate appropriate interventions such as catheterization to relieve urinary retention.
D. Raise the head of the bed.
While elevating the head of the bed can help reduce blood pressure in some situations, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Elevating the head of the bed may exacerbate autonomic dysreflexia by increasing venous return and blood pressure. Therefore, addressing the underlying cause of autonomic dysreflexia, such as bladder distention, takes priority.
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