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

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.

Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.

Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.

Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.

Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.

A. The client's forearm spasms when a blood pressure cuff is inflated on the upper arm. B. The client complains of pain when his knee is extended with his hip flexed. C. The client feels pain in the calf when his foot is dorsiflexed. D. The client has a stiff neck when the neck is flexed towards the chest.

Correct Answer is B

Explanation

Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.

Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.

Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.

Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.

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The nurse is caring for a client with Cushing's triad. The nurse expects the client to have:

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Naxlex Comprehensive Predictor Exams

The nurse cares for a client with diabetes mellitus and congestive heart failure. Exhibits Which two (2) client findings in the history and physical are most concerning? Select all that apply

Correct Answer is ["B","D"]

Explanation

A client is brought to the emergency department due to vomiting, fever, and a severe headache. The physician suspects meningitis; then assesses the client for meningeal irritation and spinal nerve root inflammation. The nurse documents a positive Kernig's sign when:

Correct Answer is B

Explanation

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