Cushings Triad is an ominous sign including the following:
Elevated blood glucose is remarkable with Cushings triad
Cushings Triad includes a positive Macawens sign
Cushings triad includes tachycardia, seizures and rapid respirations
Bradycardia, irregular respirations and a widening pulse pressure.
The Correct Answer is D
A. Elevated blood glucose is remarkable with Cushing's Triad:
Elevated blood glucose is not one of the components of Cushing's Triad. The triad focuses on cardiovascular and respiratory changes associated with increased intracranial pressure, not blood glucose levels.
B. Cushing's Triad includes a positive Macawen's sign:
Macawen's sign is not part of Cushing's Triad. Cushing's Triad is specifically related to the physiological responses seen in response to increased intracranial pressure and is not associated with Macawen's sign.
C. Cushing's Triad includes tachycardia, seizures and rapid respirations:
This option is not accurate. Cushing's Triad involves bradycardia (slow heart rate), irregular respirations, and a widening pulse pressure. Tachycardia (rapid heart rate) and seizures are not part of Cushing's Triad but might be indicative of other medical conditions or complications.
D. Bradycardia, irregular respirations and a widening pulse pressure.
Explanation: Cushing's Triad is a set of three clinical signs that are indicative of increased intracranial pressure (ICP) and are considered ominous as they suggest serious brain injury or pathology. The triad consists of:
Bradycardia: This refers to a slow heart rate. As intracranial pressure increases, it can lead to a decreased heart rate due to pressure on the brainstem, which is involved in regulating heart rate.
Irregular Respirations: Increased ICP can affect the brainstem's control over breathing, leading to irregular patterns of breathing, often known as Cheyne-Stokes respiration. This is characterized by periods of rapid breathing followed by apnea (temporary cessation of breathing).
Widening Pulse Pressure: Pulse pressure is the difference between systolic and diastolic blood pressure. An increase in ICP can cause an increase in systolic blood pressure and a decrease in diastolic blood pressure, leading to a widening pulse pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Places the infant in a side-lying position:
Positioning is important in the care of an infant with myelomeningocele. The infant is usually placed in a prone (on the abdomen) position to prevent pressure on the sac and protect the neural tissue. Placing the infant in a side-lying position may not provide the needed protection.
B) Maintains a dry dressing over the sac:
The sac should be kept moist with a sterile, non-adherent dressing moistened with saline to prevent drying and cracking, which could lead to infection.
C) Performs range of motion on the infant's hips:
Infants with myelomeningocele often have flaccid paralysis below the lesion, and excessive manipulation of the lower limbs could cause injury.
D) Takes an axillary temperature:
Rectal temperatures should never be taken, as they can cause mucosal damage or irritate the exposed spinal cord, leading to complications like meningitis. The axillary route is the safest method for temperature assessment.
Correct Answer is B
Explanation
A) Low-protein, low-potassium diet:
While low-protein and low-potassium diets can be appropriate for certain kidney conditions, such as chronic kidney disease, they are not typically the primary focus in the acute phase of glomerulonephritis. Protein restriction might be considered if there is significant kidney damage, and potassium levels are elevated.
B) Low-sodium fluid-restricted diet:
This is the most appropriate option. In acute glomerulonephritis, the kidneys' ability to regulate sodium and fluid balance may be impaired due to inflammation and decreased glomerular filtration. Fluid retention and peripheral edema are common. A low-sodium diet helps reduce fluid retention and manage edema.
C) Low carbohydrate, low-protein diet:
Low-carbohydrate and low-protein diets are not the main dietary considerations for acute glomerulonephritis. The primary focus is on managing sodium and fluid intake due to impaired kidney function.
D) Regular diet, no added salt:
A regular diet without added salt might exacerbate the fluid retention and edema associated with acute glomerulonephritis. Sodium intake needs to be controlled to prevent further fluid buildup.
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