The nurse, caring for a patient with increased intracranial pressure, assesses an increase in the intracranial pressure that is equal to the patient's mean arterial pressure
Which of the following do these findings indicate to the nurse? 1. hydrocephalus
2. Cushing's triad
3. hypoxemia
4. hypercapnia
2
Rationale: Cushing's triad develops when the intracranial pressure equals or exceeds the mean arterial pressure. Cushing's triad is an important response to cerebral ischemia and is characterized by an increase in systolic blood pressure, drop in diastolic blood pressure, and bradycardia. An increase in intracranial pressure that is equal to the patient's mean arterial pressure does not indicate hydrocephalus, hypoxemia, or hypercapnia.
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A) Cues, inferences, and goals B) Judgments and advice C) Client and nursing needs D) Validated data and suspected problems
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