You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury
During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?
a. Biot's breathing
b. Kussmaul's respirations
c. Sleep apnea
d. Cheyne-Stokes respirations
D
This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.
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A student nurse assigned to a female, observant Muslim patient noticed her discomfort with several of the male health care providers. She wonders if this discomfort is related to the patient's religious beliefs
In her preparation for clinical, she learned that Muslims differ in their adherence to tradition, but that modesty is the "overarching Islamic ethic" pertaining to interaction between the sexes (Rabin, 2010). The student nurse states which of the following to the patient? a. "I'm going to request that you only have female physicians see you. Does having male nurses bother you as well?" b. "I know that it's hard to get used to, but you just have to get used to it. That's how it is in America." c. "It must be difficult for people like you to adjust to our ways, but there are limitations for all of us." d. "I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable?'
Joan has a history of drug use and is screened for hepatitis B during the first trimester. Which action is appropriate?
a. Anticipate administering the vaccination for hepatitis B as soon as possible. b. Plan for retesting during the third trimester. c. Discuss the recommendation to bottle feed her baby. d. Practice respiratory isolation.
A nurse is caring for a premature infant with a central line. The infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status?
A) Hyperbilirubinemia B) Bacterial sepsis C) Hypoglycemia D) Intracranial hemorrhage
A nurse reminds a patient that communication in the family unit involves continual exchange of information. Which is the best example of this concept?
a. Determining the intent of the communica-tion being sent b. Determining whether the communication is functional or dysfunctional c. Accepting individual differences d. Excluding emotional responses