The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?
Regular deep respirations interspersed with periods of apnea
A pattern of crescendo-decrescendo respirations followed by a period of apnea
Patient breathing less than 10 breaths per minute
Patient breathing shallow and more than 24 breaths per minute
The Correct Answer is B
A. Regular deep respirations interspersed with periods of apnea:
This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.
B. A pattern of crescendo-decrescendo respirations followed by a period of apnea
Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.
C. Patient breathing less than 10 breaths per minute:
This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.
D. Patient breathing shallow and more than 24 breaths per minute:
This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Carotid
The nurse should avoid assessing the carotid pulses bilaterally at the same time. The carotid arteries are major blood vessels supplying the head and neck with oxygenated blood. Simultaneously assessing both carotid pulses could potentially compromise blood flow to the brain, leading to a decrease in cerebral perfusion. This is particularly important in individuals with a history of cerebrovascular disease or other conditions affecting blood flow to the brain.
B. Brachial:
Assessing the brachial pulses bilaterally at the same time is generally acceptable. The brachial pulses are located in the upper arms.
C. Popliteal:
Assessing the popliteal pulses bilaterally at the same time is generally acceptable. The popliteal pulses are located behind the knee.
D. Femoral:
Assessing the femoral pulses bilaterally at the same time is generally acceptable. The femoral pulses are located in the groin area.
Correct Answer is D
Explanation
A. He has an electrical burn, which caused coagulation of some tissues:
This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.
B. He is doing well, although he might be in the hospital for some time:
While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.
C. He does not appear to have much damage and should be fine soon:
This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.
D. He has an electrical burn. He is stable, and we will update you with any changes:
This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.
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