Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
64. The care of a client post–traumatic brain injury includes monitoring for signs of brainstem herniation and occlusion of cerebral blood flow. A nurse should recognize a deterioration in the client if which vital sign changes occurred?
Select all that apply.
Test-Taking Tip
Recognize a widening of the pulse pressure with Cushing's reflex versus hypertension with Cushing's triad.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because this change is characteristic of hypovolemic shock. Answer 2 is incorrect because respirations would slow with herniation. Rapid respirations would be characteristic of hypovolemic shock. Answer 3 is incorrect because blood pressure increases, not decreases. Answer 4 is correct because bradycardia is one of the vital sign changes with Cushing's triad, a grave sign, indicating herniation of the brainstem and occlusion of the cerebral blood flow if treatment is not initiated. Answer 5 is correct because hypertension occurs with brainstem herniation initially (Cushing's triad)—a widening pulse pressure (Cushing's reflex) occurs earlier in an attempt to overcome the increased intracranial pressure (ICP). Answer 6 is correct because bradypnea accompanies bradycardia and hypertension (Cushing's triad) with brainstem herniation.
