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. dilation reflex. B. brisk reflex, C. accommodation. D. consensual reflex

Correct Answer is D

Explanation

A. The dilation reflex refers to pupils dilating in response to dim light, not constricting.
B. A brisk reflex is an expected response, but it does not describe the bilateral pupil constriction when light is shone in one eye.
C. Accommodation refers to the process of the eyes adjusting focus for near vision, not pupil constriction in response to light.

D. Consensual reflex is when both pupils constrict in response to light shined in either one of the eyes, indicating normal neurological function.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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