The nurse is taking care of a child who is terminally ill. The nurse notices the child is having periods of shallow breathing followed by short periods of apnea. The nurse recognizes that this is:
1. Normal respiratory function of a young child.
2. Cheyne-Stokes respiration, which is a sign of imminent death. The child should be assessed for other signs of imminent death.
3. Dyspnea secondary to muscle relaxation.
4. A sign of air hunger.
2
Rationale 1: This is not normal respiratory function in a young child.
Rationale 2: Cheyne-Stokes respiration (periods of shallow breathing alternating with apnea) is a sign of imminent death.
Rationale 3: Dyspnea refers to difficulty breathing. The muscle relaxation is a symptom of imminent death and is associated with the "death rattle."
Rationale 4: With air hunger, the child's facial expression may reflect panic and the child may gasp for air.
Global Rationale:
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