Correct Answer: B — Cushing's Triad

Cushing's Triad is a late and ominous sign of severely raised intracranial pressure and impending brain herniation:

1. Hypertension (widened pulse pressure) — body attempts to perfuse brain against rising ICP
2. Bradycardia — reflex response (baroreceptor) to hypertension
3. Irregular respirations — Cheyne-Stokes or ataxic breathing due to brainstem compression

This is a medical emergency. The nurse must:

• Immediately notify the neurosurgeon and intensivist
• Elevate HOB to \(30°\)
• Administer Mannitol \(0.25 - 1 \text{ g/kg}\) IV or 3% NaCl
• Prepare for emergency ICP monitoring or surgical decompression
• Avoid hypotension (maintain CPP \(\geq 60 \text{ mmHg}\))
• Avoid hyperthermia and hypoxia

Cushing's Triad represents the last compensatory mechanism before brain herniation — survival depends on seconds-to-minutes intervention.