A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is

Kussmaul's respirations.

Cheyne-Stokes respirations.

Biot's respirations.

Hyperventilation.

Answer and Explanation

The Correct Answer is B

A.   Kussmaul's respirations are rapid, deep, and labored breaths often seen in metabolic acidosis, which does not match the pattern described.
B.   Cheyne-Stokes respirations are characterized by a pattern of deep and fast breathing followed by periods of apnea. This pattern is seen in patients with severe conditions like heart failure or brain injury.
C.   Biot's respirations are irregular, but the cycle does not have a distinct pattern of fast, slow, and apnea periods.
D.   Hyperventilation refers to an increased rate of breathing but does not involve the cycles of deep, slow, and apneic phases characteristic of Cheyne-Stokes.

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Correct Answer is C

Explanation

A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is

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Naxlex Comprehensive Predictor Exams

A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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