A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Stridor

Kussmaul respirations

Apneustic respirations

Cheyne-Stokes respirations

Answer and Explanation

The Correct Answer is D

Answer: D. Cheyne-Stokes respirations

Rationale:

A) Stridor: Stridor is a high-pitched, wheezing sound resulting from disrupted airflow in the upper airway. It is not characterized by alternating periods of hyperventilation and apnea, making this choice incorrect.

B) Kussmaul respirations: Kussmaul respirations are deep, labored breaths typically associated with metabolic acidosis, such as diabetic ketoacidosis. These respirations do not exhibit alternating periods of hyperventilation and apnea, so this option is not applicable.

C) Apneustic respirations: Apneustic respirations are characterized by prolonged inhalation followed by a prolonged pause before exhalation. This pattern does not align with the alternating hyperventilation and apnea described, making it an incorrect choice.

D) Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by a cyclical pattern of increasing depth and rate of breathing followed by a gradual decrease in depth and a period of apnea. This description matches the client's breathing pattern of alternating hyperventilation and apnea, making this the correct answer.

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Correct Answer is C

Explanation

Increasing ﬂuid intake helps to hydrate the mucous membranes and thin the respiratory secretions, which facilitates expectoration and improves gas exchange.

Encourage coughing and deep breathing. This is beneficial for clearing the airways and preventing atelectasis, but it does not directly aﬀect the viscosity of the secretions.
Encourage regular use of the incentive spirometer. This is helpful for expanding the lungs and preventing complications such as pneumonia or pleural eﬀusion, but it does not inﬂuence the consistency of the secretions.
Encourage the client to ambulate frequently. This is important for promoting circulation and mobility, but it does not have a significant eﬀect on the thinning of the secretions.

A. "We'll continue to encourage him to drink lots of ﬂuids." B. "We'll take his temperature every 4 hours." C. "We'll discard his toothbrush and buy another." D. "We'll give him Tylenol for the pain."

Correct Answer is C

Explanation

Discarding the toothbrush and buying another is a way to prevent disease transmission, as the toothbrush can harbor bacteria and reinfect the child or spread the infection to others. The toothbrush should be discarded after 24 hours of antibiotic therapy.

a) Encouraging the child to drink lots of ﬂuids is a way to promote hydration and soothe the throat, but it does not prevent disease transmission. The child should avoid sharing cups or utensils with others and use disposable tissues or paper towels.
b) Taking the child's temperature every 4 hours is a way to monitor fever, but it does not prevent disease transmission. The thermometer should be cleaned and disinfected after each use and not shared with others.
d) Giving the child Tylenol for the pain is a way to relieve discomfort, but it does not prevent disease transmission. The medication should be administered according to the label instructions and not shared with others.

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A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

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