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 A
Explanation
A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.
Correct Explanation: This intervention is appropriate for a child with an acute head injury.
Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.
B. Maintain an active stimulating environment.
Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.
Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.
C. Perform active chest percussion and suctioning every 1 to 2 hours.
Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.
Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.
D. Instruct child on performing active range of motion.
Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.
Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.
Correct Answer is ["5.625"]
Explanation
To calculate the dose of amoxicillin for the toddler:
Step 1: Convert the toddler's weight from pounds to kilograms.
33 lb ÷ 2.2 (lb to kg conversion factor) = approximately 15 kg
Step 2: Calculate the total daily dose of amoxicillin.
Dose = 30 mg/kg/day × 15 kg = 450 mg/day
Step 3: Divide the total daily dose into equal doses every 12 hours.
450 mg/day ÷ 2 doses = 225 mg/dose
Step 4: Calculate the amount of amoxicillin suspension needed for each dose.
The available concentration is 200 mg/5 mL, so for 225 mg, you would use the proportion:
225 mg : 200 mg = x mL : 5 mL
Cross-multiplying: x = (225 mg × 5 mL) / 200 mg ≈ 5.625 mL
Therefore, the nurse should administer approximately 5.625 mL of amoxicillin suspension for each dose.
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