A nurse is caring for a client in the emergency department (ED).

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

B. Cheyne-Stokes respirations involve a cyclical pattern of breathing characterized by gradual increase and decrease in the depth and rate of respirations, with periods of hyperventilation alternating with periods of apnea. It is commonly seen in patients with neurological disorders, heart failure, or drug overdose.

A. Apneustic respirations are characterized by prolonged inspiratory gasps followed by a brief pause and insufficient expiration. This pattern is often associated with damage to the pons in the brainstem.

C. Stridor is a high-pitched, noisy respiratory sound caused by turbulent airflow through partially obstructed airways. It is typically heard during inspiration and is often associated with upper airway obstruction, such as in cases of croup or epiglottitis.

D. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in patients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.

B. Right-sided heart failure leads to congestion of the systemic venous circulation, resulting in increased central venous pressure (CVP). Elevated CVP is a hallmark sign of right-sided heart failure and is often used clinically to assess right ventricular preload and volume status.

A. BNP is a hormone secreted by the heart in response to increased ventricular stretch and volume overload, and its levels are usually elevated in heart failure, including both left-sided and right-sided heart failure.

C. Specific gravity refers to the concentration of solutes in urine and is often used as a measure of urine concentration.

D. Pulmonary artery wedge pressure (PAWP) is a measure of left atrial pressure and left ventricular end- diastolic pressure. In right-sided heart failure, the primary hemodynamic abnormality is congestion of the systemic venous circulation, rather than elevated left-sided pressures.