You are an RN who is precepting a newly graduated nurse. The new grad asks you what the signs and symptoms are for a patient with Cushing's Triad.
Which of the following WOULD NOT be part of your answer?
Bradycardia.
Widening pulse pressure.
Hypertension.
Hypothermia.
The Correct Answer is D
Choice A rationale
Bradycardia, a slow heart rate (typically below 60 beats per minute in adults), is a key component of Cushing's triad. It results from the body's compensatory response to increased intracranial pressure, where systemic hypertension triggers a reflex vagal response, leading to a decrease in heart rate.
Choice B rationale
Widening pulse pressure, defined as an increasing difference between systolic and diastolic blood pressure, is a hallmark of Cushing's triad. This occurs as the body attempts to maintain cerebral perfusion pressure by increasing systolic pressure against a relatively stable or slightly decreased diastolic pressure due to peripheral vasodilation.
Choice C rationale
Hypertension, specifically systolic hypertension, is a crucial component of Cushing's triad. It reflects the body's physiological attempt to overcome increased intracranial pressure and maintain adequate cerebral blood flow by increasing systemic arterial pressure, ensuring perfusion to the brain.
Choice D rationale
Hypothermia, a core body temperature below 35°C (95°F), is not a recognized component of Cushing's triad. Cushing's triad specifically describes a set of physiological responses to increased intracranial pressure: bradycardia, hypertension, and widening pulse pressure, all related to cardiovascular and respiratory regulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The Chvostek test assesses for neuromuscular excitability, specifically facial twitching when the facial nerve is tapped. It is used to evaluate for hypocalcemia, not to determine the patency of collateral circulation before an ABG. Performing this test would not provide any relevant information for the safety of obtaining an arterial blood sample.
Choice B rationale
The Blumberg test, also known as rebound tenderness, is used in abdominal assessment to detect peritoneal inflammation. It involves pressing deeply on an area of abdominal tenderness and then quickly releasing the pressure. This test has no relevance to assessing arterial patency or collateral circulation prior to an ABG.
Choice C rationale
The Cushing's test is not a recognized medical test or diagnostic procedure. There is a "Cushing's reflex" which refers to a physiological response to increased intracranial pressure, but this is a clinical sign, not a test performed prior to an ABG. This choice is medically inaccurate in this context.
Choice D rationale
The Allen test is performed prior to obtaining an ABG, especially when considering the radial artery. It assesses the patency of the ulnar artery and ensures adequate collateral blood flow to the hand if the radial artery is compromised during or after the arterial puncture. This prevents potential ischemia to the hand, making it a crucial safety step.
Correct Answer is A
Explanation
Choice A rationale
The non-rebreather mask delivers the highest possible fraction of inspired oxygen (FiO2) among conventional oxygen delivery devices, often reaching 85-90%. This high concentration is achieved by a one-way valve system that prevents exhaled air from mixing with the inspired oxygen and a reservoir bag that stores a high concentration of oxygen. This mechanism minimizes room air entrainment, maximizing oxygen delivery to the patient's respiratory system.
Choice B rationale
A non-rebreather mask is designed to deliver high concentrations of oxygen and prevent rebreathing of exhaled gases, including carbon dioxide. The one-way valves direct exhaled air out of the mask, ensuring that the patient inhales nearly pure oxygen from the reservoir bag, thereby minimizing CO2 retention, not increasing it. This physiological effect ensures efficient gas exchange.
Choice C rationale
While a simple mask may appear less complex in its physical design, its operation still requires proper fitting and flow rate adjustment for effective oxygen delivery. The perceived simplicity does not outweigh the significant physiological advantage of a non-rebreather mask in delivering higher oxygen concentrations, which is the primary goal of oxygen therapy.
Choice D rationale
Non-rebreather masks, due to their tight seal and large reservoir bag, can exacerbate feelings of claustrophobia in some patients. Similarly, the mask's design might induce or worsen nausea in individuals prone to it, making simpler face masks or nasal cannulas often more tolerable options for these patient populations. Patient comfort and tolerance are crucial considerations in oxygen therapy.
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