A nurse caring for a client with head trauma will be monitoring the client for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Tachycardia.

Bradypnea.

Hypertension.

Bradycardia.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.

Choice B rationale

Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.

Choice C rationale

Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.

Choice D rationale

Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.

Choice E rationale

Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.

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Correct Answer is D

Explanation

Choice A rationale

The spinal accessory nerve (cranial nerve XI) controls the sternocleidomastoid and trapezius muscles, which are responsible for movements of the head and shoulders. Dysfunction in this nerve would not affect the gag reflex.

Choice B rationale

The acoustic nerve (cranial nerve VIII) is responsible for hearing and balance. Dysfunction in this nerve would lead to hearing loss and balance issues, not an absent gag reflex.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. Dysfunction here results in facial paralysis or weakness but not in the absence of a gag reflex.

Choice D rationale

The vagus nerve (cranial nerve X) innervates muscles of the pharynx and larynx, which are involved in swallowing and the gag reflex. Dysfunction in the vagus nerve would result in an absent gag reflex, which is why the nurse determines this as the issue.

A. Deficient fluid volume. B. Excessive intake of convenience foods. C. Constipation. D. Infection.

Correct Answer is C

Explanation

Choice A rationale

Deficient fluid volume is not the primary concern related to weight loss or ill-fitting dentures. While fluid intake should be monitored, it is less immediate than gastrointestinal issues from fiber deficiency.

Choice B rationale

Excessive intake of convenience foods might relate to weight loss but does not directly indicate a health risk. The primary risk is more focused on gastrointestinal function.

Choice C rationale

Constipation is a major risk due to limited fiber intake. Fiber is essential for bowel movement regularity, and its deficiency, coupled with ill-fitting dentures, increases the risk.

Choice D rationale

Infection is not directly related to the dietary concerns noted. While poor nutrition can weaken the immune system, it is not the most immediate health risk connected to the given symptoms. .

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A nurse caring for a client with head trauma will be monitoring the client for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the client has?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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