A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

BP 170/64 pulse 58

BP 180/90, pulse 96

BP 110/70, pulse 100

BP 100/60, pulse 54

Answer and Explanation

The Correct Answer is A

A. BP 170/64, pulse 58: Cushing's triad includes increased systolic blood pressure with widened pulse pressure, bradycardia, and irregular respirations, indicating increased intracranial pressure.

B. BP 180/90, pulse 96: Hypertension is present, but the elevated pulse does not align with bradycardia seen in Cushing's triad.

C. BP 110/70, pulse 100: These values do not reflect the classic signs of Cushing's triad.

D. BP 100/60, pulse 54: While bradycardia is present, hypotension does not align with Cushing’s triad.

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Correct Answer is D

Explanation

A. Elevated serum calcium levels: This is not typical for Paget's disease. While hypercalcemia can occur in advanced stages, the primary issue in Paget's disease is abnormal bone remodeling.

B. Elongated trunk: This is not characteristic of Paget's disease. Paget's disease affects bone remodeling and can lead to deformities such as bowing of the legs or enlarged bones, but not an elongated trunk.

C. Warm, swollen areas over femur: This can occur in Paget's disease due to increased blood flow to the affected bones, but it is not the most distinctive feature.

D. Mosaic pattern of bone: This pattern, which appears on X-ray, is a hallmark of Paget’s disease, indicating disorganized bone remodeling and a disruption of normal bone architecture.

A. Document the finding and continue to monitor the client. B. Prepare the client for temporary pacemaker insertion. C. Notify the client's health care provider immediately and then administer epinephrine IV. D. Administer atropine per agency bradycardia protocol and then notify the health care provider

Correct Answer is A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

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A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with Paget's disease. Which finding would the nurse identify as being characteristic of this disease?

Correct Answer is D

Explanation

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

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