Question

A nurse in the ICU is assessing a client who has traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

a. Hypotension
b. Tachypnea
c. Nuchal rigidity
d. Bradycardia

Answer 1

Bradycardia is the component of Cushing's triad identified in the assessment of a client with a traumatic brain injury in the ICU, indicating raised intracranial pressure.

Step-by-step explanation:

The nurse in the ICU assessing a client with a traumatic brain injury should recognize bradycardia as a component of Cushing's triad. Cushing's triad is a set of three primary signs that often indicate an increase in intracranial pressure, which can be a life-threatening condition. The three components of this triad are systemic hypertension, irregular respirations, and bradycardia. Typically, the nurse would observe patterns such as slowed pulse rate (bradycardia), altered respiratory patterns (irregular respirations), and high systolic blood pressure with a widening pulse pressure. It's crucial for nurses to monitor for these signs because they can precede herniation of the brain stem, which can be fatal without prompt intervention.