A nurse is assessing an elderly patient receiving palliative care who exhibits Cheyne-Stokes respirations. Which of the following characteristics should the nurse identify as indicative of this respiratory pattern?

Rapid respirations that are unusually deep and regular.

An inability to breathe without dyspnea unless sitting upright.

Breathing ranging from very deep to very shallow with periods of apnea.

Shallow breathing alternating with periods of apnea.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale

Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.

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Correct Answer is C

Explanation

Choice A rationale

While involving the family in the care of an older adult client is important, calling the family to make arrangements for someone to sit with the client is not the immediate action the nurse should take. The nurse’s first responsibility is to ensure the client’s safety and well-being.
Choice B rationale
Obtaining a prescription for medication to sedate the client is not the immediate action the nurse should take. Sedating the client does not address the immediate concern of potential injury.
Choice C rationale
The nurse should first check the client for injuries. This is the immediate action because the client may have sustained injuries from the fall. The nurse should perform a thorough assessment to determine the extent of any injuries and provide appropriate care.
Choice D rationale
Assisting the client back into bed and applying restraints is not the immediate action the nurse should take. Restraints should be used as a last resort and only if less restrictive measures have been ineffective. Furthermore, restraints require a physician’s order.

A. Provide an adaptive feeding device for the client. B. Place the client in a lateral position. C. Arrange the food groups clockwise on the plate. D. Initiate a liquid diet for the client.

Correct Answer is A

Explanation

The correct answer is choice A: Provide an adaptive feeding device for the client.

Choice A rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.

Choice B rationale: Placing the client in a lateral position might not directly address the issue of limited hand movement, and it could even make feeding more challenging. This position is typically used for clients with swallowing difficulties or those at risk of aspiration.

Choice C rationale: Arranging food groups clockwise on the plate may help clients with visual impairments or cognitive issues, but it would not directly assist a client with limited hand movement during feeding.

Choice D rationale: Initiating a liquid diet for the client is not the most appropriate initial action to address limited hand movement. This might be considered as a last resort if the client is unable to feed themselves with any type of adaptive device or assistance. The priority should be promoting independence and providing appropriate tools to support self-feeding.

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A nurse is assessing an elderly patient receiving palliative care who exhibits Cheyne-Stokes respirations. Which of the following characteristics should the nurse identify as indicative of this respiratory pattern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. What action should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?

Correct Answer is A

Explanation

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