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 C
Explanation
A. A pneumothorax occurs when there is a collapse of the lung due to air entering the pleural cavity, but this is not directly related to the lungs dropping below atmospheric pressure.
B. Air flows out of the lungs when the pressure inside the lungs is higher than atmospheric pressure (e.g., during exhalation).
C. When the pressure in the lungs drops below atmospheric pressure, it creates a vacuum effect, causing air to flow into the lungs during inhalation. This is how normal breathing works.
D. Bronchiolar constriction can cause respiratory distress, but it is not directly linked to a drop in lung pressure. Instead, constriction happens due to factors like asthma or allergies, not pressure changes.
Correct Answer is B
Explanation
A. Asthma is not typically linked to bedrest. Bedrest can lead to decreased lung expansion and impaired mucus clearance, which may increase the risk of infections like pneumonia, but it does not specifically increase the risk of asthma.
B. When a patient is immobile and unable to get out of bed, mucus can accumulate in the lungs, as normal coughing and deep breathing are reduced. This pooling of mucus provides an ideal environment for bacteria to grow, leading to pneumonia.
C. While supplemental oxygen might be needed for patients with certain respiratory conditions, it is not the primary risk factor for pneumonia in bedrest. In fact, oxygen therapy might be used to treat pneumonia.
D. Hospital-acquired infections, including pneumonia, are a concern, but the primary risk from bedrest is the inability to clear mucus effectively, not the presence of pathogens alone.
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