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. “I will begin upon the client’s admission to the facility.”
Effective discharge planning should start upon the client's admission to the facility. It is an ongoing process that involves assessing the patient's needs, planning for post-discharge care, and ensuring a smooth transition from the hospital to the next level of care. Early initiation of discharge planning allows the healthcare team to address any potential barriers, educate the patient and their family, and coordinate necessary resources for a successful transition.
B. “I will begin once the client’s insurance company approves discharge coverage.”
Waiting for insurance approval may delay the discharge planning process and hinder the timely coordination of resources needed for post-discharge care.
C. “I will begin 48 hr before the client’s discharge.”
Waiting until 48 hours before discharge may not allow sufficient time to address all aspects of the discharge plan, potentially leading to rushed or incomplete preparations.
D. “I will begin once the client’s discharge order is written.”
Waiting for the discharge order may delay the start of the planning process, and effective discharge planning should be initiated earlier to ensure comprehensive and patient-centered care.
Correct Answer is A
Explanation
A. The client:
The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.
B. Progress note:
Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.
C. Medical history:
The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.
D. Family information:
Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.
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