A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
An inability to breathe without dyspnea unless sitting upright
Shallow breathing alternating with periods of apnea
Breathing ranging from very deep to very shallow with periods of apnea
Rapid respirations that are unusually deep and regular
The Correct Answer is C
A. Inability to breathe without dyspnea unless sitting upright refers to a postural issue that might be seen in certain respiratory conditions but does not describe Cheyne-Stokes respirations.
B. Shallow breathing alternating with periods of apnea is not characteristic of Cheyne-Stokes respirations. While apnea does occur, the breathing pattern is more varied in depth.
C. Cheyne-Stokes respirations are characterized by a periodic pattern where the depth of breathing alternates between very deep and very shallow breaths, followed by periods of apnea. This is often seen in end-of-life care and is associated with respiratory distress or certain neurological conditions.
D. Rapid respirations that are unusually deep and regular are more consistent with Kussmaul respirations, which are typically seen in conditions like metabolic acidosis, not Cheyne-Stokes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rhythmic variation in breathing refers to breathing patterns such as Cheyne-Stokes respiration, not orthopnea.
B. Orthopnea is defined as difficulty breathing when lying flat, which is relieved by sitting or standing upright. It is often seen in patients with heart failure or other conditions causing fluid buildup in the lungs.
C. Difficult or labored breathing is called dyspnea, not orthopnea. While orthopnea is a type of dyspnea, the key feature of orthopnea is its positional nature.
D. Cessation of breathing is known as apnea, not orthopnea.
Correct Answer is D
Explanation
A. Inspiration is the phase when air is drawn into the lungs and alveoli.
B. Inhalation is synonymous with inspiration, referring to the process of taking air into the lungs.
C. Compliance refers to the ability of the lungs to stretch and expand, not a phase of ventilation.
D. Exhalation (or expiration) is the phase where air is expelled from the alveoli, moving out of the lungs and through the respiratory tract.
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