You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of:
A) Ataxic (Biot's) breathing
B) Cheyne-Stokes respiration
C) Kussmaul's respiration
D) COPD with prolonged expiration
B) Cheyne-Stokes respiration
Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a sign of an immediate problem. Ataxic breathing is very irregular in rhythm and depth and is seen with brain injury. Kussmaul's respiration is seen in patients with a metabolic acidosis, as they are trying to rid their bodies of carbon dioxide to compensate. Respirations in COPD are usually regular and are not usually associated with apneic episodes.
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Which most accurately describes the priority goal for wound care management in the client who has undergone surgical resection of a head and neck cancer?
1. Prevent shifts in electrolyte and fluid balances. 2. Prevent fistula development in the wound bed. 3. Prevent decubitus ulcer formation. 4. Prevent flap failure.
The nurse is preparing a presentation on the menstrual cycle for a group of high school students. Which statement should the nurse include in this presentation?
1. "The menstrual cycle has five distinct phases that occur during the month." 2. "One hormone controls the phases of the menstrual cycle." 3. "The secretory phase occurs when a woman is most fertile." 4. "Menstrual cycle phases vary in order from one woman to another."
The mother of a 4-year-old child is concerned that the child
will need glasses because of the inability to distinguish pictures at a distance when tested with the Snellen chart. What should the nurse respond to this mother? A) "He might be suffering from hyperopia and probably will need glasses now." B) "Children's vision is not completely developed by this age. Your child might outgrow this nearsightedness." C) "He is likely to have a slight astigmatism, which almost always needs to be corrected by glasses." D) His vision problem will get in the way of his learning, so he will probably have to have glasses before he starts school."
The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration
The student is asked about client behaviors that are most likely to occur during this phase. Which of the following responses, made by the student, indicates an under-standing of this phase? 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client is self-focused and talks to others about labor."