A nurse is assessing a client who is experiencing Cushing's triad due to increased intracranial pressure. Which of the following findings should the nurse expect?
Severe hypertension
Narrowed pulse pressure
Diastolic murmur
Increased heart rate
The Correct Answer is A
A. Severe hypertension: Cushing’s triad is characterized by increased systolic blood pressure with widening pulse pressure as a compensatory response to maintain cerebral perfusion during increased intracranial pressure. Severe hypertension is a hallmark finding.
B. Narrowed pulse pressure: In Cushing’s triad, the pulse pressure is typically widened, not narrowed, due to elevated systolic pressure and relatively lower diastolic pressure. Narrowed pulse pressure does not reflect the classic pattern associated with increased ICP.
C. Diastolic murmur: A diastolic murmur is a cardiac finding unrelated to increased intracranial pressure and is not a component of Cushing’s triad. It does not provide information about cerebral perfusion or ICP.
D. Increased heart rate: Cushing’s triad involves bradycardia rather than tachycardia, as part of the body’s compensatory response to elevated ICP. An increased heart rate is inconsistent with this classic presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Offer high-calorie, high-protein snacks to the client: Providing nutrient-dense snacks helps address nutritional deficits caused by decreased appetite in depression. High-calorie, high-protein foods can improve energy levels, support overall health, and help prevent weight loss, which is a common concern in clients with depression.
B. Encourage the client to eat foods selected by the dietitian: While following a dietitian’s plan is beneficial, clients with depression and poor appetite may be resistant to structured meal plans. Offering flexible, appealing snacks is more practical and effective for ensuring adequate intake.
C. Weigh the client once each day: Daily weighing can be stressful or discouraging for clients with depression and may not directly improve nutritional intake. Weight monitoring is important but is secondary to actively supporting adequate nutrition through appealing foods.
D. Recommend the family provide the client privacy during meals: Privacy during meals may be helpful for some clients, but clients with depression often require encouragement, social support, and practical assistance to eat. Simply providing privacy may not address the underlying lack of appetite or insufficient nutrient intake.
Correct Answer is D
Explanation
A. BUN 22 mg/dL (10 to 20 mg/dL): A slightly elevated BUN indicates mild renal impairment or dehydration but does not typically require withholding enoxaparin. Monitoring renal function is important, but this value alone is not a contraindication for anticoagulation.
B. WBC count 15,000/mm3 (5,000 to 10,000/mm3): An elevated WBC suggests possible infection or inflammation. While it may warrant further assessment, it does not directly increase the risk of bleeding and is not a reason to withhold enoxaparin.
C. Urine specific gravity 1.04 (1.005 to 1.03): A high specific gravity may indicate dehydration but is not a contraindication for enoxaparin administration. The medication can be given with caution while monitoring renal function and fluid status.
D. Platelets 80,000/mm3 (150,000 to 400,000/mm3): Thrombocytopenia significantly increases the risk of bleeding while on enoxaparin, which is an anticoagulant. Withholding the dose and notifying the provider is essential to prevent hemorrhagic complications and ensure safe management of the client.
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