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 C

Explanation

A. Temperature often decreases in cases of severe blood loss due to shock and hypothermia.
B. A decrease in pulse is unlikely in severe blood loss. The body compensates with an increased heart rate.
C. A decrease in blood pressure is expected in cases of significant blood loss, as the body struggles to maintain adequate circulation.
D. Respirations may increase in response to blood loss, not decrease, as the body attempts to increase oxygen intake.

A. push the soles of the feet against the nurse's hands. B. wiggle the toes of both feet at the same time. C. pull both feet up at the same time to stretch the Achilles tendons. D. stand up independently

Correct Answer is A

Explanation

A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.

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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

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