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 B
Explanation
A. Beneficence: Beneficence refers to the ethical principle of promoting good and acting in the best interest of the client. While this guides nursing actions to provide beneficial care, it does not directly involve respecting a client’s decision to refuse treatment.
B. Autonomy: Autonomy is the ethical principle that recognizes the client’s right to make independent decisions about their own healthcare. Respecting the client’s decision to refuse treatment honors their personal values, beliefs, and right to self-determination, even if the nurse disagrees with the choice.
C. Nonmaleficence: Nonmaleficence involves the obligation to avoid causing harm to the client. While important in all nursing actions, it focuses on preventing harm rather than specifically supporting a client’s right to make healthcare decisions.
D. Justice: Justice refers to fairness in the distribution of healthcare resources and treatment. It ensures equitable care for all clients but is not directly related to respecting an individual client’s choice to accept or refuse treatment.
Correct Answer is B
Explanation
A. Polyuria: Excessive urination is more commonly associated with conditions such as diabetes mellitus or diabetes insipidus, and is not a primary indicator of laxative misuse in clients with anorexia nervosa.
B. Positive Trousseau's sign: A positive Trousseau's sign indicates hypocalcemia, which can result from electrolyte imbalances caused by chronic laxative misuse. Laxative overuse can lead to loss of potassium, magnesium, and calcium, increasing the risk of neuromuscular irritability and positive Trousseau's sign.
C. Jaundice of the sclera: Scleral jaundice suggests liver dysfunction or hemolysis, which is not directly related to laxative misuse. While malnutrition can affect liver function, jaundice is not a specific indicator of laxative overuse.
D. Hypoglycemia: Low blood glucose may occur in clients with anorexia nervosa due to inadequate nutritional intake, but it is not a direct consequence of laxative misuse. Electrolyte disturbances are more characteristic findings in laxative overuse.
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