PNLE Nursing Practice II Neurological Care, Increased ICP & Stroke Management (Topnotcher Rapid Cram Study System)

Cushing’s Triad vs Shock & Glasgow Coma Scale (GCS): CUSHING'S TRIAD (Increased ICP - Herniation Imminent): 1. Systolic Hypertension with Widening Pulse Pressure (e.g. 190/60) 2. Bradycardia (Bounding pulse) 3. Irregular Respiration (Cheyne-Stokes breathing) *Contrast with Hypovolemic Shock: Hypotension, Tachycardia, Tachypnea! GLASGOW COMA SCALE (Max 15, Coma ≤ 8): • Eye Opening (4 Spontaneous, 3 To sound, 2 To pain, 1 None) • Verbal Response (5 Oriented, 4 Confused, 3 Inappropriate, 2 Incomprehensible, 1 None) • Motor Response (6 Obeys commands, 5 Localizes pain, 4 Flexion withdrawal, 3 Decorticate, 2 Decerebrate, 1 None) ---------------------------------------- PRACTICE BOARD QUESTION & RATIONALE: Q: A post-craniotomy patient develops a widening pulse pressure with BP rising from 120/70 to 182/64, heart rate drops from 80 to 48 bpm, and respirations become irregular. Which intervention is contraindicated? A. Elevating head of bed 30 degrees B. Administering 20% Mannitol IV with a filter needle C. Administering a bolus of 500 mL 5% Dextrose in Water (D5W) D. Hyperventilating the intubated client to maintain PaCO2 30-35 mmHg Correct Answer: C. D5W becomes hypotonic once dextrose is metabolized in the body, causing free water to shift into swollen brain cells and exacerbating fatal cerebral edema.