Philippine Nursing Master Study & Reviewer

High-Yield Board Mnemonic: Cushing's Triad vs Shock: 🌸 CUSHING'S TRIAD (Increased ICP - Brain Herniation Danger): 1. Systolic Hypertension with Widening Pulse Pressure (e.g., 185/60 mmHg) 2. Bradycardia (Bounding slow pulse < 60 bpm) 3. Irregular Respiration (Cheyne-Stokes breathing) 🌿 CONTRAST WITH HYPOVOLEMIC SHOCK: Hypotension (Low BP), Tachycardia (Rapid HR > 100), Tachypnea (Rapid RR > 20)! ✨ PRC BOARD EXAM TIP: In acute traumatic brain injury or post-craniotomy, NEVER administer hypotonic fluids (like D5W or 0.45% Saline) because fluids will shift into swelling brain tissue. Always prepare 20% Mannitol IV with a filter needle or 3% Hypertonic Saline as ordered! ---------------------------------------- PRACTICE BOARD QUESTION & RATIONALE: Q: A 24-year-old post-craniotomy client manifests a blood pressure shift from 118/74 to 176/58 mmHg, heart rate decreases from 78 to 44 bpm, and exhibits irregular Cheyne-Stokes respirations. Which nursing action takes absolute priority? A. Place the client in Trendelenburg position immediately B. Elevate the head of the bed 30 degrees and notify the neurosurgeon C. Administer an IV bolus of 500 mL normal saline rapidly D. Perform vigorous endotracheal suctioning for 25 seconds Correct Answer: B. Elevate HOB 30° to enhance jugular venous return without hip flexion. Manifests Cushing's Triad indicating impending cerebral herniation!