The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT

  • cardiac arrhythmia.
  • increased blood pressure.
  • irregular respirations.
  • decreased heart rate.
Number 1 is correct.
The classic Cushing’s triad includes increased blood pressure, irregular respirations, and decreased heart rate. This triad indicates an emergency situation of increasing intracranial pressure, usually leading to brain herniation or death if not immediately treated. Cardiac arrhythmia is not part of the Cushing reflex triad.