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 B
Explanation
Choice A rationale
Swelling of the optic nerve, also known as papilledema, can be a sign of increased intracranial pressure (ICP). However, it is not a direct indicator of a worsening neurological condition.
Choice B rationale
The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient’s level of consciousness and neurological functioning. A decreasing GCS score indicates a worsening neurological condition, which could be due to increasing ICP12. Therefore, a decreasing GCS score is a direct indicator of a worsening neurological condition.
Choice C rationale
A blood pressure of 108/76 mm Hg is within the normal range and does not directly indicate a worsening neurological condition. However, drastic changes in blood pressure could potentially indicate a problem.
Choice D rationale
Changes in pupil size and shape can be a sign of increased ICP, but these changes are not specific to a worsening neurological condition. They could be due to various factors, including medication effects or damage to the cranial nerves.
Choice E rationale
A respiratory rate of 12/min is within the normal range for adults. Changes in respiratory patterns could potentially indicate a worsening neurological condition, but a rate of 12/min does not directly indicate this.
Correct Answer is D
Explanation
Choice A rationale
Monitoring volume status is important in managing increased ICP, but it is not a direct intervention to reduce ICP78.
Choice B rationale
Ensuring proper ventriculostomy transducer levels is important in monitoring ICP, but it is not a direct intervention to reduce ICP78.
Choice C rationale
Managing sedation can help control agitation and excessive muscular activity, which can potentially increase ICP. However, it is not a direct intervention to reduce ICP78.
Choice D rationale
Elevating the head of the bed 15 degrees can help promote venous drainage, enhance cerebral perfusion, and reduce ICP78.
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