In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?
With elevated blood glucose.
When death is imminent.
During an allergic reaction.
After strenuous exercise.
The Correct Answer is B
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.
Correct Answer is D
Explanation
A. Exploring the client’s thoughts about dying is supportive but not the immediate priority when a specific request for a religious ritual is made.
B. Notifying the family of the request is a secondary action but should follow the immediate fulfillment of the client's request for spiritual support.
C. Suggesting that the hospital chaplain is available might be appropriate, but the client's specific request was for a priest, and it is better to offer to contact the priest directly.
D. Offering to contact the priest for the client directly addresses the client's immediate spiritual need and respects their request.
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