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. The cerebellum is involved in coordinating movement and balance but is not primarily responsible for regulating respiration.
B. The diencephalon is involved in sensory processing and regulation of autonomic functions but does not directly control respiration.
C. The cerebral cortex is involved in voluntary control over breathing (such as when you hold your breath), but the central regulation of breathing is managed by the brainstem.
D. The brainstem (specifically the medulla oblongata and pons) is the primary control center for respiration. It regulates the rate and depth of breathing by responding to levels of oxygen and carbon dioxide in the blood.
Correct Answer is C
Explanation
A. The septum refers to the nasal septum, which divides the nasal cavity into two nostrils. It is not part of the pharynx.
B. The oropharynx is located below the nasopharynx and serves as a passage for both air and food. It is not the most superior portion of the pharynx.
C. The nasopharynx is the most superior portion of the pharynx, located behind the nasal cavity and above the soft palate. It is primarily involved in the passage of air from the nasal cavity to the rest of the respiratory system.
D. The laryngeal pharynx (or hypopharynx) is the portion of the pharynx below the oropharynx, just above the larynx, and it
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