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: Bell's palsy is not caused by a bacterial infection; hence, antibiotics are not the primary treatment.
Choice B rationale: Corticosteroids like prednisone are often used to reduce inflammation and improve symptoms in Bell's palsy.
Choice C rationale: While vitamins can support overall health, they are not the primary treatment for Bell's palsy.
Choice D rationale: Surgery is not the primary treatment for Bell's palsy unless certain complications arise.
Correct Answer is D
Explanation
Choice A rationale: This refers to postrenal AKI, which is caused by an obstruction in the urinary tract that prevents urine from leaving the body.
Choice B rationale: This refers to AKI in general and is not specific compared to choice D.
Choice C rationale: This refers to intrinsic AKI, which is caused by damage to the kidney tissue or cells from various causes, such as inflammation, infection, toxins, or ischemia.
Choice D rationale: This is correct because it is pre-renal AKI, a condition in which kidney blood flow may become significantly reduced, including cases where a significant amount of fluid has been lost. This situation suggests potential hypovolemia (low blood volume) due to the massive GI bleed, which can lead to reduced kidney blood flow and subsequent acute kidney injury.
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