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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Epistaxis refers to nosebleed, which is unrelated to lung function or expansion.
B. Effusion refers to the accumulation of fluid (such as pleural effusion, where fluid collects in the pleural space around the lungs), not incomplete lung expansion.
C. Atelectasis is the collapse or incomplete expansion of a lung or part of a lung, which can occur due to blockage, pressure, or injury.
D. Adhesion refers to abnormal fibrous connections between tissues, which can occur in the body after injury or surgery, but it does not refer to incomplete lung expansion
Correct Answer is B
Explanation
A. Elevated WBC count and increased serum potassium are not common side effects of bronchodilators. These might be seen in other conditions or medications, but not typically with bronchodilators.
B. Nervousness, palpitations, and tremors are common side effects of bronchodilators, particularly beta-agonist bronchodilators like albuterol. These symptoms occur because bronchodilators stimulate beta receptors in the body, leading to increased heart rate and stimulation of the nervous system.
C. Urinary retention and gynecomastia are more commonly associated with other medications, such as anticholinergics or certain hormonal treatments, not bronchodilators.
D. Steven Johnson Syndrome is a rare and severe skin reaction that can occur with certain medications, but it is not a common side effect of bronchodilators.
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