The nurse is taking care of a child who is showing signs of imminent death. What changes should the nurse expect to see with the respiratory system?
1. Periods of shallow breathing alternating with apnea
2. Dyspnea and increased breath sounds
3. Muscles tightening with secretion accumulation in the bronchi
4. Normal cardiac function
1
Rationale:
1. Cheyne-Stokes respiration (periods of shallow breathing alternating with apnea) is a sign of imminent death.
2. Impaired cardiac function leads to pulmonary congestion, tachypnea, diminished breath sounds, and hypoxia.
3. As the muscles relax, secretions accumulate in the oropharynx and bronchi. The "death rattle" is caused by air passing through these secretions.
4. Impaired cardiac function leads to pulmonary congestion, tachypnea, diminished breath sounds, and hypoxia.
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