Question

A client has just arrived in the critical care unit with concerns of increased intracranial pressure. Which changes in vital signs would confirm the development of Cushing's Triad? (Select all that apply).

Answer 1

Correct Answers:

Altered respiratory pattern
Systolic Hypertension
Bradycardia

Rationale :

🎀 Cushing's Triad is a late sign of increased intracranial pressure and includes hypertension, bradycardia, and irregular respirations.

🎀 Systolic hypertension occurs due to increased sympathetic output as the brain attempts to maintain cerebral perfusion.

🎀 Bradycardia results from vagal stimulation due to pressure on the brainstem.

🎀 Altered respiratory pattern stems from medullary involvement affecting respiratory centers.

🎀 Recognition of these signs is critical for prompt neurological intervention.

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Answer 2

Correct Answers:

24

Rationale :

🔷Convert pounds to kg: 132 lb ÷ 2.2 = 60 kg

🔷 Multiply: 0.4 mcg/kg/min × 60 kg = 24 mcg/min

🔷 Nitroprusside dosing is weight-based, and accurate conversion is critical to avoid hypotension.

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Answer 3

Correct Answers:

Protect airway

Rationale :

👍 Airway is always the priority per ABCs in seizure response.

👍 During a seizure, jaw clenching or tongue obstruction can compromise breathing.

👍 The nurse should position the client side-lying to allow drainage of secretions.

👍 Documentation and medication come after safety measures.

👍 Delayed airway protection can lead to hypoxia and aspiration.

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Answer 4

Correct Answers:

22.5%

Rationale :

◆ Anterior chest/abdomen = 18%

◆ Anterior left arm = 4.5%

◆ Total Burn Surface Area (TBSA) = 18 + 4.5 = 22.5%

◆ TBSA guides fluid resuscitation and risk stratification.

◆ Accurate Rule of Nines assessment is essential in initial burn triage.

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Answer 5

Correct Answers:

6750 mL

Rationale :

⧫ Convert 165 lb → 75 kg

⧫ Formula: 4 mL × TBSA (%) × weight (kg)

⧫ 4 × 22.5 × 75 = 6,750 mL

⧫ Administer half in first 8 hrs, rest over next 16 hrs

⧫ Accurate calculation prevents hypovolemia or over

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Answer 6

Correct Answers:

3375 mL

Rationale :

🎀 From total 24-hr volume (6,750 mL), divide by 2 = 3,375 mL

🎀 Initial 8 hours are critical for preventing burn shock

🎀 Administer with close hourly monitoring

🎀 Use large-bore IV access for rapid infusion

🎀 Monitor urine output to assess perfusion response

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Answer 7

Correct Answers:

Hyperkalemia
Hyponatremia

Rationale :

◆ Hyperkalemia results from cell lysis and K⁺ leakage into blood

◆ Hyponatremia occurs due to fluid shifts and capillary leakage

◆ Burn shock alters electrolyte balance and volume status

◆ Labs guide fluid resuscitation and electrolyte replacement

◆ Continuous monitoring is required to prevent arrhythmias or neuro symptoms

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Answer 8

Correct Answers:

14

Rationale :

◆ Eye opening = 4

◆ Verbal response (confused) = 4

◆ Motor response (obeys commands) = 6

◆ Total = 4 + 4 + 6 = 14

◆ Indicates mild head injury or disorientation

◆ GCS helps track neurologic recovery or deterioration

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QLexNursing

1 :
A client has just arrived in the critical care unit with concerns of increased intracranial pressure. Which changes in vital signs would confirm the development of Cushing's Triad? (Select all that apply).

2 :
The client is receiving an IV infusion of nitroprusside (Nitropress) at 0.4 mcg/kg/min. The client weighs 132 Ib. How many mcg is the client receiving per minute? mcg/min (If needed, round to the nearest whole number.)

3 :
The nurse is reviewing the posturing changes that occur with head injuries. Identify the posture that demonstrates decerebrate. A client in the emergency department starts to have seizure like activity. Which action should the nurse take first

4 :
A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. What is the total body surface area (TBSA) burned?

5 :
A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. what is the total body surface area (TBSA) burned? The client weighs 165 pounds. According to the Parkland Burn formula, what is the total amount of fluids needed in the first 24 hours?

6 :
A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. what is the total body surface area (TBSA) burned? The client weighs 165 pounds. According to the Parkland Burn formula, what is the total amount of fluids needed in the first 8 hours

7 :
Which laboratory changes would the nurse expect with a client who suffered burns to 22.5% of the body?

8 :
A clients in the post anesthesia care unit eyes open spontaneously, they are confused, and obey all commands. How should the nurse interpret the Glasgow Coma Scale.

QLexNursing

1 : A client has just arrived in the critical care unit with concerns of increased intracranial pressure. Which changes in vital signs would confirm the development of Cushing's Triad? (Select all that apply).

2 : The client is receiving an IV infusion of nitroprusside (Nitropress) at 0.4 mcg/kg/min. The client weighs 132 Ib. How many mcg is the client receiving per minute? mcg/min (If needed, round to the nearest whole number.)

3 : The nurse is reviewing the posturing changes that occur with head injuries. Identify the posture that demonstrates decerebrate. A client in the emergency department starts to have seizure like activity. Which action should the nurse take first

4 : A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. What is the total body surface area (TBSA) burned?

5 : A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. what is the total body surface area (TBSA) burned? The client weighs 165 pounds. According to the Parkland Burn formula, what is the total amount of fluids needed in the first 24 hours?

6 : A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. what is the total body surface area (TBSA) burned? The client weighs 165 pounds. According to the Parkland Burn formula, what is the total amount of fluids needed in the first 8 hours

7 : Which laboratory changes would the nurse expect with a client who suffered burns to 22.5% of the body?

8 : A clients in the post anesthesia care unit eyes open spontaneously, they are confused, and obey all commands. How should the nurse interpret the Glasgow Coma Scale.

1 :
A client has just arrived in the critical care unit with concerns of increased intracranial pressure. Which changes in vital signs would confirm the development of Cushing's Triad? (Select all that apply).

2 :
The client is receiving an IV infusion of nitroprusside (Nitropress) at 0.4 mcg/kg/min. The client weighs 132 Ib. How many mcg is the client receiving per minute? mcg/min (If needed, round to the nearest whole number.)

3 :
The nurse is reviewing the posturing changes that occur with head injuries. Identify the posture that demonstrates decerebrate. A client in the emergency department starts to have seizure like activity. Which action should the nurse take first

4 :
A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. What is the total body surface area (TBSA) burned?

5 :
A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. what is the total body surface area (TBSA) burned? The client weighs 165 pounds. According to the Parkland Burn formula, what is the total amount of fluids needed in the first 24 hours?

6 :
A client presents to the emergency department with burns to the anterior chest/abdomen and anterior left arm. what is the total body surface area (TBSA) burned? The client weighs 165 pounds. According to the Parkland Burn formula, what is the total amount of fluids needed in the first 8 hours

7 :
Which laboratory changes would the nurse expect with a client who suffered burns to 22.5% of the body?

8 :
A clients in the post anesthesia care unit eyes open spontaneously, they are confused, and obey all commands. How should the nurse interpret the Glasgow Coma Scale.