A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Irregular respirations with frequent periods of apnea

Irregular respirations greater than 20/min

Regular, rapid, shallow respirations

Regular respirations fewer than 12/min

Answer and Explanation

The Correct Answer is A

Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.

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Correct Answer is D

Explanation

The nurse should first palpate the abdomen to assess for signs of appendicitis, such as rebound tenderness, guarding, or rigidity. Appendicitis is a medical emergency that requires prompt diagnosis and treatment to prevent rupture and peritonitis.

A. Move a vibrating tuning fork in front of the client's ear canals one after the other. B. Place the base of a vibrating tuning fork on the client's mastoid process. C. Place the base of a vibrating tuning fork on the top of the client's head. D. Count how many seconds a client can hear a tuning fork after it has been struck

Correct Answer is C

Explanation

The Weber's test is used to assess for unilateral hearing loss caused by either conduction or sensorineural impairment. The nurse places a vibrating tuning fork on the midline of the client's head and asks if he hears it better in one ear or equally in both ears. A normal finding is that the sound is heard equally in both ears (no lateralization). If there is conduction deafness in one ear, the sound will be heard louder in that ear (lateralization to affected ear). If there is sensorineural deafness in one ear, the sound will be heard louder in the opposite ear (lateralization to unaffected ear).

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A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test?

Correct Answer is C

Explanation

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