A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad.
The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?

Brainstem ischemia

Tachycardia

Agonal breathing

Chest pain

Answer and Explanation

The Correct Answer is A

Choice A rationale
Cushing’s Triad, which includes bradycardia (low heart rate), irregular respiration, and widened pulse pressure, is a nervous system response that could prevent brainstem ischemia. Brainstem ischemia is a condition where there is insufficient blood flow to the brainstem, which can lead to cell death.
Choice B rationale

While tachycardia (high heart rate) is a serious condition, it is not typically prevented by Cushing’s Triad.
Choice C rationale
Agonal breathing, which is characterized by gasping, labored breathing, particularly when lying flat, is not typically prevented by Cushing’s Triad.
Choice D rationale
Chest pain is not typically prevented by Cushing’s Triad. Cushing’s Triad is a response to increased intracranial pressure, not a cardiac condition.

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Correct Answer is B

Explanation

Choice A rationale
Pulmonary embolus is a serious condition that can occur due to prolonged immobility, but it is not directly related to the timing of enteral nutrition in a client with increased intracranial pressure.

Choice B rationale
Bacterial translocation refers to the migration of bacteria from the gut to other areas of the body. Early enteral nutrition (within 24 to 48 hours) in critically ill patients can help maintain the integrity of the gut mucosa and prevent bacterial translocation. Therefore, starting enteral nutrition within this timeframe can help prevent bacterial translocation.
Choice C rationale
Deep vein thrombosis, like pulmonary embolus, is a risk due to immobility but is not directly related to the timing of enteral nutrition.
Choice D rationale
Myocardial infarction is a cardiac event that could be related to overall cardiovascular health, stress, or specific injury to the cardiac muscle. It is not directly prevented by the initiation of enteral nutrition.

A. Trigeminal neuralgia B. Lhermitte’s sign C. MS hug D. Paroxysmal spasms

Correct Answer is C

Explanation

Choice A rationale
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. It does not cause a sensation of tightness around the torso.
Choice B rationale

Lhermitte’s sign is a symptom of multiple sclerosis and other neurological conditions where a person feels an electric shock-like sensation running down the spine and into the limbs. It does not cause a sensation of tightness around the torso.
Choice C rationale
The sensation of tightness around the torso in a patient with multiple sclerosis is often referred to as the “MS hug”. It is caused by a lesion or an area of active inflammation within the spinal cord.
Choice D rationale
Paroxysmal spasms are a type of muscle spasm experienced by some people with multiple sclerosis. These spasms are usually painful and involve the muscles of the legs, but they do not cause a sensation of tightness around the torso.

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A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad. The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Correct Answer is B

Explanation

A nurse is attending to a client with multiple sclerosis who reports a sensation of tightness around their torso. What condition should the nurse identify this symptom as indicating?

Correct Answer is C

Explanation

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A nurse is gathering neurological data on a patient with a neurological injury and observes signs indicative of Cushing’s Triad.
The nurse understands that Cushing’s Triad is a nervous system response that could prevent which of the following conditions?