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
Hyperoxia, or high oxygen levels, can cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated. Too much oxygen can lead to oxygen toxicity and cause damage to the lungs and other organs, including the brain.
Choice B rationale
A platelet count of 250,000/mm^3 is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice C rationale
A hemoglobin level of 16 g/dL is within the normal range and would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Choice D rationale
A Glasgow Coma Scale score of 16 is not possible as the maximum score is 15. A higher score indicates a less severe injury, so it would not typically cause unfavorable outcomes for a client who has a traumatic brain injury and is being mechanically ventilated.
Correct Answer is A
Explanation
Choice A rationale
Rebleeding of the injury is a significant factor related to a high mortality rate for a client who has a subarachnoid hemorrhage (SAH). SAH is a devastating event with substantial mortality and high morbidity among survivors. The most common primary causes of death or neurological devastation leading to withdrawal of support are direct effects of the primary hemorrhage (55%) and aneurysm rebleeding (17%)2. Therefore, rebleeding of the injury is a critical concern in the management of SAH.
Choice B rationale
Decreased cerebrospinal fluid is not directly linked to a high mortality rate in SAH. While changes in cerebrospinal fluid dynamics can occur after SAH, it’s not typically a primary factor contributing to mortality.
Choice C rationale
The use of nimodipine is actually part of the treatment protocol for SAH. Nimodipine is a calcium channel blocker that is used to prevent cerebral vasospasm, a complication of SAH. It does not contribute to a higher mortality rate.
Choice D rationale
Poor functional ability could be a result of SAH due to neurological damage, but it is not a direct cause of high mortality. The severity of the initial hemorrhage and subsequent
complications like rebleeding or medical complications are more directly tied to mortality rates.
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