A client with a severe traumatic brain injury is exhibiting signs of dysphagia.
What should the nurse do first to ensure safe feeding?

Assessment of respiratory patterns in terminal patients involves identifying neurological and metabolic shifts. This scenario requires knowledge of breathing cycles, specifically the crescendo-decrescendo pattern and apnea associated with brainstem dysfunction or advanced heart failure during end-of-life care.

Choice A rationale

Kussmaul respirations involve deep, rapid breathing typically seen in metabolic acidosis. This pattern is a compensatory mechanism to expel excess carbon dioxide, lowering arterial acidity, and is distinct from the cyclic apnea seen in terminal brain injury.

Choice B rationale

Cheyne-Stokes is characterized by rhythmic waxing and waning of breathing depth followed by apnea. It occurs due to delayed feedback in the respiratory center, often seen in stroke, traumatic brain injury, or profound heart failure.

Choice C rationale

Biot respirations involve clusters of shallow breaths followed by irregular periods of apnea. This occurs with damage to the medulla oblongata and lacks the rhythmic, gradual increase and decrease in depth seen in the Cheyne-Stokes pattern.

Choice D rationale

Orthopnea is the physical inability to breathe comfortably while lying flat. It is common in congestive heart failure and pulmonary edema, requiring the patient to sit upright to decrease venous return and improve diaphragmatic excursion.

Circumferential full-thickness burns to the chest create an inelastic eschar that restricts thoracic excursion. Knowledge of burn pathophysiology and respiratory mechanics is needed to identify life-threatening restrictive lung disease and the urgent need for a surgical escharotomy.

Choice A rationale

High pressure ventilator alarms occur when the ventilator meets resistance while delivering a breath. While this indicates a problem, it is a machine notification of the physiological restriction caused by the chest eschar and not the root observation.

Choice B rationale

Increasing peak pressures reflect decreased lung compliance or increased airway resistance. In this scenario, the pressures rise because the chest wall cannot expand, but the mechanical measurement is secondary to the physical assessment of chest movement.

Choice C rationale

Decreased thoracic expansion in a circumferential burn patient indicates the eschar is acting as a tourniquet. This prevents lung inflation, leading to rapid respiratory failure. This physical finding confirms the immediate need for an emergency escharotomy.

Choice D rationale

A SpO2 of 90 percent indicates hypoxemia, which is a significant clinical sign. However, it is a late manifestation of the underlying mechanical restriction. The priority is identifying the physical cause, which is the lack of expansion.