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 B

Explanation

A. Suppresses ectopic ventricular sites: Atropine primarily increases heart rate; it does not directly suppress ectopic ventricular activity.

B. Increases SA node automaticity: Atropine blocks the parasympathetic nervous system, increasing SA node activity and heart rate in cases of bradycardia or asystole.

C. Increases myocardial contractility: This effect is more related to drugs like inotropes (e.g., dopamine), not atropine.

D. Decreases AV node conduction: Atropine actually increases conduction through the AV node by blocking vagal stimulation.

A. Compartment syndrome B. Muscle wasting C. Skin breakdown D. Joint Stiffness

Correct Answer is A

Explanation

A. Compartment syndrome. The client’s unrelieved pain, despite analgesics, and the presence of swelling distal to the cast are warning signs of compartment syndrome. This is a medical emergency that occurs when increased pressure within a closed muscle compartment reduces blood flow, leading to tissue damage and pain.

B. Muscle wasting. Muscle wasting typically occurs over time due to disuse and is not a sudden, acute complication like compartment syndrome.

C. Skin breakdown. Skin breakdown could occur from improper cast fitting or prolonged pressure, but it would not cause unrelieved pain in the same way as compartment syndrome.

D. Joint stiffness. Joint stiffness can occur in casted limbs after removal, but it is not an acute complication like compartment syndrome.

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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 caring for a client with advanced coronary artery disease who has developed cardiac arrest. During the resuscitation, the health care provider prescribes atropine. Which is the intended outcome of this medication?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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