A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

respirations gradually decreasing in rate and depth.

rapid wheezing respirations for two or three breaths with short periods of apnea.

a breathing pattern of dyspnea followed by a short period of apnea.

quick shallow respirations with long periods of apnea.

Answer and Explanation

The Correct Answer is C

A.   Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B.   Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C.   Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D.   Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

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Correct Answer is B

Explanation

A. While auscultating lung and abdominal sounds is important, it is not as urgent as checking neurological function in a head trauma patient.
B. Assessing verbal and motor responses is critical to evaluate the level of consciousness and neurological function in a patient with head trauma.
C. Monitoring daily weight is not an immediate concern for a patient with possible head trauma.
D. Monitoring intake and output is important but not the priority compared to assessing the neurological status in head trauma patients.

A. frequency B. duration C. location. D. character E. intensity

Correct Answer is ["A","B","C","D","E"]

Explanation

A. The frequency of pain is essential to understand how often the patient experiences pain.
B. Duration refers to how long the pain lasts, which is an important characteristic to document.
C. The location of pain helps determine its origin and the appropriate treatment approach.
D. The character of the pain, such as sharp, dull, or aching, aids in identifying its nature and cause.
E. The intensity of pain is crucial for assessing the effectiveness of pain management and guiding treatment decisions.

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A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

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Naxlex Comprehensive Predictor Exams

A patient was admitted with possible head trauma after a motor vehicle accident. The nursing implementation with the highest priority is to:

Correct Answer is B

Explanation

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

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