The nurse is caring for a client with a traumatic brain injury. Which assessment finding indicates that the client is experiencing Cushing's triad?

Correct Answer: A

Rationale: Cushing's triad (hypertension, widened pulse pressure, bradycardia) from ICP is seen in BP 180/60, pulse 50 (A). Others (B, C, D) don't match. A is correct. Rationale: Triad reflects brainstem compression, a late brain injury sign, per neurocritical care, requiring urgent intervention.

Correct Answer: A

Rationale: Noise levels below 85 decibels are generally safe for hearing, per occupational and health standards. Prolonged exposure above this like 95 or higher risks damage, while 110 or 120 is immediately harmful. Nurses assess this to protect clients, especially in hospitals where equipment or activity might elevate levels. Maintaining a quiet environment below 85 supports healing and prevents auditory stress, a key environmental consideration in care.

Correct Answer: D

Rationale: Transitional epithelium changes shape with bladder fullness, stretching thin when full, a unique adaptation. It's stratified, not single-layered, and lacks special elastic substances. This aids nursing assessment of urinary function.

Correct Answer: A

Rationale: A washcloth in the sink prevents denture damage if dropped, best for safety. Pulling by the clasp, hot water, or overnight soaking risks harm. Nurses ensure this for equipment care.

Correct Answer: A

Rationale: Carbohydrates like grains form the food pyramid base, recommended most for energy, over vegetables, dairy, or proteins. Nurses teach this for balanced diets.