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 A
Explanation
Choice A rationale: Yeast vaginitis, commonly known as a yeast infection, is typically caused by an overgrowth of Candida albicans, a type of fungus. Candida albicans overgrowth can lead to symptoms like white, thick discharge and itching in the vaginal area.
Choice B rationale: Lactobacillus acidophilus is a bacterium associated with maintaining vaginal health rather than causing yeast infections.
Choice C rationale: Escherichia coli is a bacteria that can cause different types of infections but are not typically associated with yeast vaginitis.
Choice D rationale: Neisseria gonorrhoeae is a bacteria and does not cause yeast vaginitis despite having similar presentation such as pus discharge per vaginally.
Correct Answer is B
Explanation
Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.
Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.
Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.
Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.
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