Question

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

1) Decreased heart rate
2) Decreased blood pressure
3) Irregular respirations
4) Increased intracranial pressure

Answer 1

The nurse should identify increased intracranial pressure, increased blood pressure, irregular respirations, and decreased heart rate as components of Cushing's triad in a client with a traumatic brain injury.

Step-by-step explanation:

The nurse should identify increased intracranial pressure as a component of Cushing's triad in a client with a traumatic brain injury. Cushing's triad is a set of clinical signs that indicate increased intracranial pressure and potential brainstem herniation. The triad includes increased blood pressure, irregular respirations, and bradycardia (decreased heart rate).