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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Related Questions
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.
Correct Answer is C
Explanation
A. The external exchange of gases refers to the process of oxygen diffusing from the alveoli into the blood and carbon dioxide diffusing from the blood into the alveoli in the lungs. This occurs during pulmonary ventilation.
B. Pulmonary ventilation involves the movement of air in and out of the lungs (breathing), not the exchange of gases.
C. The internal exchange of gases refers to the diffusion of oxygen from the blood to the tissues and carbon dioxide from the tissues to the blood. This happens at the cellular level throughout the body.
D. This answer is incorrect because internal exchange of gases is the correct phase for oxygen to diffuse out of the blood.
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