A nurse is caring for a client who has a sustained intracranial pressure (ICP) reading of 35 mm Hg. Which of the following findings indicate that the client is experiencing Cushing’s triad? (Select all that apply)

Choice A rationale: Slurred speech is a neurological finding often associated with stroke or mild increases in ICP, but it is not a specific component of the late-stage physiological response known as Cushing’s triad. Choice B rationale: A decrease in heart rate, or bradycardia, occurs as a compensatory response to significantly elevated intracranial pressure. The body attempts to manage increased blood pressure by slowing the heart rate. Choice C rationale: Irregular breathing patterns, such as Cheyne-Stokes respirations, occur due to brainstem compression. As ICP rises to dangerous levels, the respiratory center in the medulla becomes impaired, causing unpredictable breathing. Choice D rationale: Neck stiffness, or nuchal rigidity, is a classic sign of meningeal irritation, often seen in meningitis or subarachnoid hemorrhage. It is not considered one of the three components of Cushing’s triad. Choice E rationale: Hypertension, specifically a widening pulse pressure where the systolic blood pressure rises significantly, is a hallmark of the triad. It represents a desperate attempt to maintain cerebral perfusion against high ICP.