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 C
Explanation
Choice A rationale
Administering acetaminophen by mouth for pain control is important, but it is not the first intervention that should be implemented for a client who has had a traumatic fall. Pain management is crucial, but it is not the immediate priority in this situation.
Choice B rationale
Performing a thorough health history is a part of the nursing assessment, but it is not the first intervention in an acute situation such as a traumatic fall. Immediate physical needs and potential injuries need to be addressed first.
Choice C rationale
Preparing for a STAT non-contrast CT scan is the correct answer. After a traumatic fall, it is crucial to quickly assess for potential injuries, especially to the brain. A CT scan can help identify any immediate life-threatening conditions such as bleeding in the brain.
Choice D rationale
Inserting an indwelling urinary catheter to monitor urine output is an intervention that may be necessary depending on the client’s condition, but it is not the first intervention to be implemented after a traumatic fall.
Correct Answer is D
Explanation
Choice A rationale
Osmotic cerebral edema is a condition where water moves from the blood vessels into the brain due to changes in the concentration of particles in the blood. However, this is not the primary cause of cerebral edema in meningitis.
Choice B rationale
While inflammation can contribute to cerebral edema, it is not specific to the brain and does not affect the brain the most. In meningitis, the inflammation is primarily in the meninges, the membranes that cover the brain, and not the whole body.
Choice C rationale
Cerebrospinal fluid (CSF) does flow from the intraventricular space to the interstitial area of the brain, but this is a normal process and does not cause cerebral edema. In meningitis, the inflammation of the meninges can disrupt the normal flow and absorption of CSF, leading to an accumulation of fluid and increased intracranial pressure.
Choice D rationale
In meningitis, the inflammation and immune response to the infection can lead to an increase in the permeability of the blood-brain barrier. This allows fluid and immune cells to enter the brain tissue, leading to cerebral edema. Additionally, the by-products of the pathogen that causes meningitis can directly damage the brain tissue and contribute to the edema.
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