In which client situation should the practical nurse (PN) assess for the presence of Cheyne-Stokes respirations?

During an allergic reaction.

When death is imminent.

With elevated blood glucose.

After strenuous exercise.

Answer and Explanation

The Correct Answer is B

Rationale:

A. During an allergic reaction: Allergic reactions typically produce bronchoconstriction, wheezing, and possible hypoxia, but they do not cause the cyclical pattern of waxing and waning respirations characteristic of Cheyne-Stokes breathing. Assessment should focus on airway patency and oxygenation rather than this specific respiratory pattern.

B. When death is imminent: Cheyne-Stokes respirations, marked by periods of progressively deeper and faster breathing followed by apnea, often occur in clients with severe neurologic compromise, heart failure, or in the dying process. This pattern reflects impaired central respiratory regulation and is most commonly observed near end-of-life.

C. With elevated blood glucose: Hyperglycemia can lead to Kussmaul respirations, which are deep and rapid, but this is distinct from Cheyne-Stokes breathing. The PN should assess for metabolic compensation rather than cyclical respiratory patterns when blood glucose is elevated.

D. After strenuous exercise: Post-exercise tachypnea is typically regular and related to increased metabolic demand, not Cheyne-Stokes respirations. The breathing pattern is usually symmetric and resolves with rest, differing from the periodic apnea and hyperventilation cycles of Cheyne-Stokes.

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Correct Answer is B

Explanation

Rationale:

A. Encourage dangling feet over side of the bed: Dangling the feet increases hydrostatic pressure in the lower extremities and can worsen edema. This intervention is not appropriate for managing pitting edema and could exacerbate fluid accumulation.

B. Enter computer documentation of the finding: Accurately documenting the observed 2+ pitting edema ensures that the client’s current condition is recorded objectively. Documentation allows the healthcare team to track changes over time, evaluate the effectiveness of interventions, and guide further assessment or treatment decisions.

C. Increase the elevation of the feet: Elevating the feet can help reduce edema by promoting venous return, but it is an intervention rather than an initial assessment action. The PN should first document and communicate findings before implementing changes unless directed by a provider.

D. Notify the charge nurse immediately: Immediate notification is warranted if the client’s condition is unstable or worsening. Since the edema has actually decreased from 4+ to 2+, this represents an improvement rather than an urgent deterioration, immediate reporting is not necessary.

A. Request the client to reach for a spoon on the breakfast tray. B. Tell the client to touch themself on the nose with a forefinger 5 times. C. Have the client to use both hands to grip and squeeze the PN's hands. D. Ask the client to extend both arms to the side and move in small to larger circles.

Correct Answer is C

Explanation

Rationale:

A. Request the client to reach for a spoon on the breakfast tray: Reaching for objects evaluates coordination and fine motor skills more than gross muscle strength. While it can provide some information, it is not a standardized or reliable method to assess upper extremity strength.

B. Tell the client to touch themself on the nose with a forefinger 5 times: This maneuver, known as the finger-to-nose test, assesses coordination, proprioception, and cerebellar function. It does not provide an accurate measure of muscle strength in the upper extremities.

C. Have the client use both hands to grip and squeeze the PN's hands: Handgrip strength testing is a direct, objective method to evaluate upper extremity muscle strength. By having the client squeeze the PN’s hands, the nurse can compare bilateral strength and identify weakness that may indicate neurologic impairment following a TIA.

D. Ask the client to extend both arms to the side and move in small to larger circles: This movement tests range of motion and coordination rather than strength. It is useful for assessing motor control but does not quantify or reveal muscle weakness effectively.

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In which client situation should the practical nurse (PN) assess for the presence of Cheyne-Stokes respirations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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