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 C

Explanation

Choice A rationale

A blood pressure of 100/70 mm Hg, while potentially lower than a client's baseline, does not directly indicate worsening intracranial pressure (ICP) in isolation. Worsening ICP often presents with Cushing's triad: hypertension (increased systolic pressure), bradycardia, and irregular respirations. A normal blood pressure range is typically 90/60 mm Hg to 120/80 mm Hg. This reading is within normal limits and doesn't suggest acute deterioration.

Choice B rationale

An increased intracranial pressure (ICP) is the underlying problem, not a direct cue of *worsening* condition in terms of a specific neurological sign. While elevated ICP is the pathology, the question asks for *cues* of worsening. Normal ICP ranges from 5 to 15 mmHg. A sustained increase above this range indicates worsening cerebral perfusion and potential herniation.

Choice C rationale

A decreasing Glasgow Coma Scale (GCS) score is a critical indicator of worsening neurological function. The GCS assesses eye opening, verbal response, and motor response, providing a quantitative measure of consciousness. A decrease in the score signifies a deterioration in brain function, often due to increasing ICP compromising cerebral blood flow and neuronal activity.

Choice D rationale

A respiratory rate of 12/min is within the normal adult range (12 to 20 breaths per minute). While changes in respiratory patterns, such as Cheyne-Stokes or Kussmaul respirations, are indicative of neurological deterioration, a normal rate alone does not signal worsening intracranial pressure or neurological status.

A. Blood pressure 184/92 mm Hg. B. Bilateral flank pain. C. Distended jugular veins. D. Generalized urticaria.

Correct Answer is D

Explanation

Choice A rationale

A blood pressure of 184/92 mm Hg, indicating hypertension, is not a typical or primary sign of an allergic transfusion reaction. Allergic reactions often lead to vasodilation and hypotension due to widespread histamine release. Elevated blood pressure might suggest fluid overload or another co-existing condition, but not allergic response.

Choice B rationale

Bilateral flank pain is a characteristic symptom of an acute hemolytic transfusion reaction, where the recipient's antibodies attack and destroy transfused red blood cells. This symptom is related to renal damage and is distinct from the immunological mechanisms of an allergic reaction.

Choice C rationale

Distended jugular veins are indicative of fluid volume overload or cardiac decompensation, which can be a complication of rapid intravenous fluid administration during a transfusion. However, this is a circulatory finding, not a direct manifestation of an allergic hypersensitivity reaction.

Choice D rationale

Generalized urticaria, or the presence of hives all over the body, is a common and hallmark sign of an allergic transfusion reaction. This reaction is mediated by mast cell and basophil degranulation, releasing histamine that causes increased vascular permeability and pruritic skin lesions.

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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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Correct Answer is C

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Correct Answer is D

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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.