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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A persistent cough can indicate lung cancer or other types of cancer affecting the respiratory system, making it a warning sign that should be noted.
B. Difficulty swallowing, or dysphagia, can be indicative of cancer in the esophagus, throat, or mouth, and should raise concern when observed.
C. Changes in pulse rate are typically not direct indicators of cancer; however, they could result from underlying conditions related to cancer treatment or progression.
D. An obvious change in a mole, especially in size, shape, or color, is a well-known warning sign of skin cancer, specifically melanoma.
E. Vesicular breath sounds are normal breath sounds, not linked to cancer.
F. Hyperactive bowel sounds could indicate a gastrointestinal issue but are not specific to cancer.
Correct Answer is C
Explanation
A. Waiting 30 minutes is unnecessary unless there is concern about an acute change in the patient's condition.
B. While both readings can be recorded, the difference between arms should be noted, as it can indicate underlying issues such as vascular problems.
C. It is important to retake the blood pressure on both arms to verify accuracy and check for any significant discrepancy.
D. Retaking the pressure on just one arm may miss important information about the other arm's readings.
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