A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care.
Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
Rapid respirations that are unusually deep and regular.
Breathing ranging from very deep to very shallow with periods of apnea.
Shallow to normal breaths alternating with periods of apnea.
An inability to breathe without dyspnea unless sitting upright.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["13376"]
Explanation
This scenario requires calculating fluid resuscitation requirements for a burn patient. Knowledge of the Parkland formula is necessary to determine the total volume of isotonic crystalloids required based on weight and the percentage of total body surface area burned.
Step 1 is 4 mL × 88 kg × 38 percent.
Step 2 is 352 × 38.
Step 3 is 13376 mL.
Correct Answer is A
Explanation
Biliary obstruction prevents the flow of bile into the duodenum, leading to systemic accumulation of bile components. This scenario requires applying knowledge of hepatic and biliary biochemical markers to differentiate between hepatocellular damage and obstructive cholestatic patterns.
Choice A rationale
Biliary obstruction causes cholestasis. Total bilirubin (normal 0.3 to 1.0 mg/dL), alkaline phosphatase (normal 30 to 120 units/L), and GGT (normal 8 to 38 units/L) all rise because they are concentrated in the obstructed bile ducts.
Choice B rationale
In an obstructive process, alkaline phosphatase and GGT are typically significantly elevated alongside bilirubin. Normal levels of these enzymes would point toward a hemolytic cause of jaundice rather than a mechanical obstruction of the biliary tree.
Choice C rationale
Obstructive jaundice is characterized by the accumulation of bile pigments and enzymes in the blood. Low levels of these markers are inconsistent with the clinical presentation of jaundice, dark urine, and pruritus from bile salt deposition.
Choice D rationale
Amylase and glucose elevations are markers for pancreatic dysfunction or metabolic stress. While biliary stones can cause pancreatitis, low AST levels are unlikely in hepatobiliary disease, and these markers do not confirm a biliary obstruction..
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