The nurse is caring for a client with Cushing's triad. The nurse expects the client to have:
Irregular respirations, bradycardia, and widening pressure
Hypotension, jugular venous distention, and mufled heart sound
Fixed pupils, hypertension, and bradycardia
Bradycardia, hypotension, and bradypnea
The Correct Answer is C
Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.
Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.
Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),
hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.
Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Her healthcare provider prescribing a calcium channel blocker for hypertension is not directly linked to lymphedema.
Choice B rationale: Sustaining an insect bite to her left arm yesterday - Trauma or injury, such as an insect bite, to the affected limb post-mastectomy can increase the risk of
lymphedema.
Choice C rationale: Losing twenty pounds since the surgery might influence overall health but doesn’t specifically relate to lymphedema.
Choice D rationale: Her hobby of playing classical music on the piano is unrelated to the risk of developing lymphedema.
Correct Answer is B
Explanation
Choice A rationale: This is not accurate since the manifestations of facial nerve paralysis are observed on the contralateral side which in this case is the left side of the face hence the right facial nerve is paralyzed.
Choice B rationale: Facial nerve paralysis cause symptoms such as drooping of the eyelid, cheek or mouth as depicted in the above picture. The right facial nerve is paralyzed since the nerve innervates the contralateral side hence the effects are demonstrated on the
left side of the face.
Choice C rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
Choice D rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
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