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: This patient is likely experiencing hyperosmolar hyperglycemic state (HHS). Rapid administration of IV fluids is crucial to correct severe dehydration associated with HHS.
Choice B rationale: Routine insulin therapy and exercise might be components of diabetes management but wouldn't directly address the immediate concern of severe dehydration and high blood glucose.
Choice C rationale: Cardiac monitoring for potassium changes might be necessary but isn't the primary immediate intervention for HHS.
Choice D rationale: Administering a different antibiotic for the UTI is incorrect, because there is no evidence that the current antibiotic is ineffective or causing adverse effects. The UTI may have triggered the HHS, but it is not the main problem that needs to be addressed urgently.
Correct Answer is A
Explanation
Choice A rationale: Petit mal seizures, also known as absence seizures, involve a sudden lapse in consciousness for a brief duration, typically 5 to 30 seconds.
Choice B rationale: Clonic seizures involve rhythmic jerking movements.
Choice C rationale: Tonic-clonic seizures involve both tonic (muscle stiffness) and clonic (rhythmic jerking) phases.
Choice D rationale: Tonic seizures involve muscle stiffness but don't usually present as sudden lapses of consciousness in a short duration.
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