A nurse is collecting neurologic data on a client who has a neurological injury and notes changes suggestive of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent which of the following conditions?

Tachycardia

Agonal breathing

Chest pain

Brainstem ischemia

Answer and Explanation

The Correct Answer is D

Cushing's Triad is a set of three classic signs associated with increased intracranial pressure (ICP). These signs include hypertension, bradycardia, and irregular respirations. The presence of Cushing's Triad indicates severe brain injury or increased ICP, often leading to brainstem compression.

A. Tachycardia (Option A): Increased intracranial pressure can initially lead to tachycardia as the body attempts to compensate for the changes. However, as ICP continues to rise and brainstem compression occurs, the sympathetic response diminishes, resulting in bradycardia rather than tachycardia. Therefore, Cushing's Triad is not associated with preventing tachycardia.

B. Agonal breathing (Option B): Agonal breathing, characterized by gasping, labored breathing, or irregular breathing patterns, may occur as a result of brainstem dysfunction or damage. Cushing's Triad, indicative of increased ICP and impending brainstem herniation, does not prevent agonal breathing. In fact, irregular respirations are part of Cushing's Triad.

C. Chest pain (Option C): Chest pain may occur due to various cardiac or respiratory conditions and is not directly related to Cushing's Triad or increased intracranial pressure. Therefore, Cushing's Triad does not prevent chest pain.

D. Brainstem ischemia (Option D): Increased intracranial pressure can lead to brainstem compression, compromising blood flow to the brainstem and resulting in brainstem ischemia. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, is a nervous system response indicative of severe brain injury or increased ICP, which can lead to brainstem ischemia if left untreated. Therefore, Cushing's Triad is associated with brainstem ischemia rather than preventing it.

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Correct Answer is C

Explanation

A. "I notice the ringing when I'm not concentrating on something." This statement suggests that the client notices the tinnitus but does not imply a significant impact on their well-being. It indicates that the tinnitus occurs when the client is not focused on tasks, which may not necessarily affect their overall functioning or well-being.

B. "I am still able to complete my work in a timely manner." This statement indicates that the client can still function adequately in their work despite experiencing tinnitus. While this may suggest some level of coping, it does not directly address the impact of tinnitus on the client's overall well-being.

C. "The ringing in my ears is distracting." This is the correct answer. This statement indicates that the tinnitus is distracting to the client, which suggests that it may affect their concentration, focus, or overall quality of life. The distraction caused by tinnitus can significantly impact daily activities and well-being.

D. "Hopefully a treatment for this ringing in my ears will help." While this statement acknowledges the presence of tinnitus and the desire for treatment, it does not directly address the impact of tinnitus on the client's well-being. It focuses more on the hope for relief through treatment rather than the current impact on their quality of life.

A. Third spacing B. Cardiomyopathy C. Cardiac tamponade D. Ruptured aneurysm

Correct Answer is C

Explanation

A. Third spacing: Third spacing refers to the shifting of fluid from the intravascular space into the interstitial space, leading to decreased circulating volume. While third spacing can contribute to hypovolemic shock, it is not specific to obstructive shock.

B. Cardiomyopathy: Cardiomyopathy is a condition characterized by abnormalities in the heart muscle structure and function. While cardiomyopathy can lead to heart failure, it is not directly associated with obstructive shock.

C. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing its ability to fill properly. This condition can lead to obstructive shock due to decreased cardiac output. Signs and symptoms include hypotension, muffled heart sounds, distended neck veins, and pulsus paradoxus.

D. Ruptured aneurysm: A ruptured aneurysm can lead to hypovolemic shock due to acute blood loss. While it can cause significant hemodynamic instability, it is not a characteristic diagnosis of obstructive shock.

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A nurse is collecting neurologic data on a client who has a neurological injury and notes changes suggestive of Cushing's Triad. The nurse understands that Cushing's Triad is a nervous system response that might prevent which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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