The three components of Cushing's response are: (Select all that apply.)
a. Increased pulse rate
b. Increased blood pressure
c. Widened pulse pressure
d. Bradycardia
e. Increased systolic blood pressure
f. Uncontrolled thermoregulation
C, D, E
A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing's response. It is considered an important diagnostic sign of late-stage brain herniation.
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A nurse is working with an elderly patient with Alzheimer's disease and congestive heart failure in the ICU
Which of the following methods of pain assessment would be essential to include in this situation, according to the American Geriatric Society? A) No assessment is appropriate; the patient should be started on a standardized protocol for analgesia for Alzheimer's patients B) The verbal zero to ten scale C) The word descriptor scale D) Assessment of behavior and family observations
The nurse anticipates that the patient who has had a subtotal gastrectomy will need supplemental:
a. protein due to the loss of some of the digestive processes. b. vitamin B12 due to the loss of the intrinsic factor. c. bulk to prevent constipation. d. vitamin A due to the loss of the gastric lining.
A child with Duchenne's muscular dystrophy rises from the floor by walking up the thighs with the hands. The nurse records this observation as:
a. hand-assistance. b. leg crawling. c. Gowers' sign. d. Bright's sign.
Which drug for insomnia can cause amnesia?
a. Amitriptyline (Elavil) b. Diphenhydramine (Benadryl) c. Temazepam (Restoril) d. Trazodone (Desyrel)