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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm a diagnosis of a migraine.
Choice B rationale
Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the question “Are the lights in here bothering you?” is less specific to migraines as it could be indicative of several other conditions as well.
Choice C rationale
While confusion or clouded thinking can occur with migraines, it is not as common as other symptoms such as nausea, vomiting, and sensitivity to light.
Choice D rationale
Unusual smells, known as olfactory hallucinations, are not typically associated with migraines. They are more commonly associated with conditions such as epilepsy.
Choice E rationale
Weakness before the headache started or currently feeling weak now is not a typical symptom of migraines. It could be indicative of a more serious condition, such as a stroke.
Correct Answer is D
Explanation
Choice A rationale
Regulation of the amount of carbon dioxide exhaled can affect cerebral blood flow, but it does not directly maintain cerebral perfusion pressure constant.
Choice B rationale
Catecholamines circulating throughout the body can affect blood pressure and heart rate, but they do not directly maintain cerebral perfusion pressure constant.
Choice C rationale
How much blood is pumped from the heart, also known as cardiac output, can affect cerebral perfusion pressure. However, it does not directly maintain cerebral perfusion pressure constant.
Choice D rationale
Regulation of constriction and dilation of blood vessels in the brain, also known as cerebral autoregulation, is a key mechanism that maintains cerebral perfusion pressure constant. When pressure autoregulation is impaired, cerebral blood flow becomes dependent on cerebral perfusion pressure.
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