A nurse is caring for a 75-year-old male client in the neuro-intensive care unit following a fall at home.

Select the four findings that indicate Cushing's Triad and require immediate follow-up.

Increased blood pressure

Widening pulse pressure

Bradycardia

Tachypnea

Episodes of apnea

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale: Increased blood pressure is a hallmark component of Cushing’s triad, which signals increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by elevating systemic arterial pressure. This compensatory mechanism is critical but also dangerous, as it reflects a decompensating neurologic state. In this client, the blood pressure increased from 140/60 mm Hg to 148/54 mm Hg, indicating a rising trend that requires immediate intervention.

Choice B rationale: Widening pulse pressure, defined as an increasing difference between systolic and diastolic pressures, is another component of Cushing’s triad. It results from increased systolic pressure due to sympathetic stimulation and decreased diastolic pressure from peripheral vasodilation. In this case, the pulse pressure widened from 80 mm Hg (140–60) to 94 mm Hg (148–54), suggesting worsening intracranial hypertension and impending brain herniation if not addressed urgently.

Choice C rationale: Bradycardia is a classic sign of Cushing’s triad and occurs as a reflex response to increased ICP. The pressure on the brainstem affects the vagus nerve, leading to a decreased heart rate. The client’s heart rate dropped from 55/min to 52/min, which, although subtle, is concerning in the context of other signs of increased ICP and must be followed up immediately to prevent further neurologic deterioration.

Choice D rationale: Tachypnea is not part of Cushing’s triad. In fact, the client is exhibiting shallow respirations and intermittent apnea, which are more consistent with brainstem dysfunction due to elevated ICP. Tachypnea would suggest a different pathophysiologic process, such as metabolic acidosis or pulmonary compromise, and is not indicative of Cushing’s triad.

Choice E rationale: Episodes of apnea are highly concerning in the context of increased ICP and brainstem compression. Apnea reflects impaired respiratory drive from medullary dysfunction, which is a late and ominous sign. When seen alongside bradycardia and hypertension with widened pulse pressure, it confirms the presence of Cushing’s triad and necessitates immediate neurologic intervention to prevent irreversible brain injury.

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Correct Answer is A

Explanation

Choice A rationale

Assessing the client for bladder distention is the priority action. Autonomic dysreflexia is a medical emergency in individuals with spinal cord injury above T6, triggered by noxious stimuli below the level of injury. A common cause is bladder distention, which acts as a strong afferent stimulus. Emptying the bladder can often alleviate the hypertensive crisis by removing the initiating stimulus, thus preventing further complications like stroke or seizure.

Choice B rationale

Placing the client in a high-Fowler's position is an important intervention to help manage the severe hypertension associated with autonomic dysreflexia. Gravity can aid in venous pooling in the lower extremities, thereby reducing venous return to the heart and consequently lowering blood pressure. However, identifying and removing the trigger (like bladder distention) takes precedence over positional changes.

Choice C rationale

Administering a nitrate antihypertensive, such as nifedipine or hydralazine, may be necessary if conservative measures (identifying and removing the trigger, positioning) do not resolve the severe hypertension. However, pharmacological intervention is a secondary step. The immediate priority is to identify and remove the underlying cause of the autonomic dysreflexia before administering medication, as addressing the cause can often resolve the crisis without drugs.

Choice D rationale

Obtaining the client's heart rate is part of a complete vital sign assessment during autonomic dysreflexia. While blood pressure is markedly elevated, bradycardia (slow heart rate) often accompanies the hypertension due to vagal stimulation above the level of the spinal cord injury. Monitoring heart rate is crucial for a comprehensive understanding of the client's physiological response but does not take precedence over identifying the precipitating stimulus. .

A. TALK. B. RACE. C. FUP. D. FAST.

Correct Answer is D

Explanation

Choice A rationale

TALK is not a recognized acronym for stroke manifestations. Acronyms like FAST are specifically designed to help the public quickly recognize the common signs of a stroke, emphasizing the urgency of seeking medical attention. Using an unrelated acronym could lead to confusion and delay in diagnosis and treatment.

Choice B rationale

RACE is an acronym often used in the context of emergency response, particularly for fire safety (Rescue, Alarm, Contain, Extinguish), or for rapid assessment of stroke in prehospital settings focusing on specific deficits. However, it is not the most widely recognized or comprehensive acronym for teaching the general public about common stroke manifestations for initial recognition.

Choice C rationale

FUP is not a recognized acronym for stroke manifestations. It does not correspond to any common set of signs or symptoms associated with a stroke. Using an arbitrary acronym would not be effective for public health education regarding stroke recognition and timely intervention.

Choice D rationale

FAST is a widely recognized and effective acronym for remembering common manifestations of a stroke. Each letter represents a key sign: F for Facial drooping, A for Arm weakness, S for Speech difficulty, and T for Time to call emergency services. This acronym emphasizes the importance of rapid recognition and seeking immediate medical attention, as time is critical in stroke treatment.

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A nurse is caring for a 75-year-old male client in the neuro-intensive care unit following a fall at home. Select the four findings that indicate Cushing's Triad and require immediate follow-up.

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A nurse is caring for a 75-year-old male client in the neuro-intensive care unit following a fall at home.

Select the four findings that indicate Cushing's Triad and require immediate follow-up.