A patient with a severe head injury begins to exhibit Cushing's triad. The nurse would assess for which combination of vital signs?

Appeared in: NORCET 9 Prelims-2025

Explanation

Cushing's triad is a classic, late sign of severely increased intracranial pressure (ICP).
It is characterized by a specific set of three vital sign changes that occur as a physiological response to brainstem compression.
The correct combination is hypertension (specifically with a widening pulse pressure), bradycardia (a slow heart rate), and an irregular respiratory pattern.
This triad signals that the brain's ability to autoregulate has failed and that brain herniation is imminent, constituting a medical emergency.

Option B: This combination is incorrect. Hypotension and tachycardia are classic signs of hypovolemic or distributive shock, not Cushing's triad. Kussmaul respirations are typically associated with metabolic acidosis, such as in diabetic ketoacidosis (DKA).
Option C: This option is incorrect because it includes tachycardia (a fast heart rate). A key component of Cushing's triad is bradycardia (a slow heart rate) as a reflex response to severe hypertension.
Option D: This option is incorrect because it includes hypotension (low blood pressure). Cushing's triad is characterized by a significant increase in blood pressure (hypertension) as the body tries to perfuse the brain.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of Cushing's triad components to guide bedside assessment, documentation, and the next nursing action.
Cushing's triad is a late and ominous sign of increased ICP. Its appearance indicates a neurosurgical emergency requiring immediate intervention to prevent brain herniation and death.
Nurses must perform frequent and accurate neurological assessments (including vital signs, GCS, and pupillary response) on all patients at risk for increased ICP.
Immediate reporting of these findings to the physician is critical for initiating life-saving measures like administering osmotic diuretics (mannitol), hypertonic saline, or preparing for surgical decompression.

How to Approach the Question

First, identify the key term in the question: 'Cushing's triad'. This is a specific clinical sign with a defined set of components.
Recall the pathophysiology of increased intracranial pressure (ICP). Remember that Cushing's triad is a late, decompensatory response.
Systematically recall the three parts of the triad: the effect on blood pressure, heart rate, and respirations.
Evaluate each option against the three components. Look for the option that correctly lists hypertension, bradycardia, and an abnormal breathing pattern.
Eliminate options that contain signs opposite to the triad, such as hypotension or tachycardia.

Concept Tested & Keywords

Concept Tested: Identification of Cushing's triad components
Stem keywords: severe head injury, Cushing's triad, vital signs
Lead-in keywords: assess for which combination
Clinical cues: The patient has a severe head injury, which is a primary cause of increased intracranial pressure (ICP).

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 30-32, 89-91

Practise the full NORCET 9 Prelims-2025

Attempt every question from this paper in a timed mock, then review the full solution for each one.