A nurse is assessing a client who is experiencing Cushing's triad due to increased intracranial pressure. Which of the following findings should the nurse expect?
Explanation & Rationale
A. Severe hypertension: Cushing’s triad is characterized by increased systolic blood pressure with widening pulse pressure as a compensatory response to maintain cerebral perfusion during increased intracranial pressure. Severe hypertension is a hallmark finding. B. Narrowed pulse pressure: In Cushing’s triad, the pulse pressure is typically widened, not narrowed, due to elevated systolic pressure and relatively lower diastolic pressure. Narrowed pulse pressure does not reflect the classic pattern associated with increased ICP. C. Diastolic murmur: A diastolic murmur is a cardiac finding unrelated to increased intracranial pressure and is not a component of Cushing’s triad. It does not provide information about cerebral perfusion or ICP. D. Increased heart rate: Cushing’s triad involves bradycardia rather than tachycardia, as part of the body’s compensatory response to elevated ICP. An increased heart rate is inconsistent with this classic presentation.