The nurse recognizes the presence of Cushing's triad in the patient with which vitals? Show A. Increase pulse, irregular respirations, increased BP
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Chapter 57: Nursing Management: Acute Intracranial Problems Terms in this set (10)The nurse recognizes the presence of Cushing's triad in the patient with B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations. Vasogenic cerebral edema increases ICP by B. Altering the endothelial lining of cerebral capillaries A patient with ICP monitoring has pressure of 12 mm Hg. The nurse understand that this pressure reflects D. A normal balance between brain tissue, blood, and CSF- normal is 10- 15 mm Hg
The nurse plans care for a patient with increased ICP with the knowledge that the best way to position the patient is to B. elevate the head of the bed to 30 degrees The
nurse is alerted to possible acute subdural hematoma in the patient who C. develops decreased LOC and a headache within 48 hours of head injury During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for A. Patency of airway is the #1 priority with all head injuries A patient is suspected of
having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the A. Frontal lobe Nursing management of a patient with a brain tumor includes (select all that
apply) C, E The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale A nursing measure that is indicated to reduce the potential for seizures and increased ICP in the patient with bacterial meningitis is B. Controlling fever with prescribed drugs and cooling techniques Sets found in the same folderMed-Surg: Lewis: Chapter 57: Acute Intracranial Pr…68 terms gvilleshirley Med Surge Lewis Chapter 57 Acute Intercranial prob…25 terms Jay0721 LEWIS: Chapter 61: Peripheral Nerve and Spinal Cor…40 terms Tara_Rowland Med-Surg: Lewis: Chapter 57: Acute Intracranial Pr…68 terms carolanne22 Other sets by this creatorCOTA Ch. 47 Problems of Urinary Function Questions12 terms mh63507 Lewis Chapter 59 - Chronic Neurologic Problems (Pr…5 terms mh63507 Lewis Chapter 58 - Stroke (Pre-test, Bridge NCLEX,…10 terms mh63507 chapter 5610 terms mh63507 Other Quizlet setsFinance 1.5 - CHAPTER 1 + 225 terms valentinas0275 Barron's GRE with sentences - Complete Wordlist2,000 terms shobhit_awasthi1987 REG - Chapter 3107 terms will_wortmann Related questionsQUESTION What makes up the contents of the skull? 10 answers QUESTION Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage? 15 answers QUESTION What are the manifestations of fibrocystic breast disease? 8 answers QUESTION What is the most common shoulder pathology? 15 answers What are the signs of Cushing's triad?The Cushing Triad (Cushing's Triad or Cushing's Reflex) is characterized by: Hypertension. Bradycardia. Irregular respirations – primarily Cheyne-Stokes breathing.. Increased blood pressure.. Decreased heart rate.. Decreased respiratory rate (effort). Which group of vital sign changes is associated with Cushing's reflex?The classic Cushing response is comprised of a triad of clinical signs including increased systolic pressure/wide pulse pressure, bradycardia, and respiratory irregularity. Increased intracranial pressure leads to diminished perfusion pressure within the brain.
What happens first in Cushing's triad?The sympathetic stimulation also increases the rate of heart contractions and cardiac output. Increased heart rate is also known as tachycardia. This combined with hypertension is the first stage of the Cushing reflex.
Which of the following are signs of Cushing triad quizlet?Cushing's triad is systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and slowed respirations.
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The nurse recognizes the presence of cushings triad in the patient with which vital sign changes?
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