Author Question: Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with ... (Read 117 times)

rayancarla1 · **on:** Jul 23, 2018

Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with pe-riods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse re-ports this respiratory assessment as:

1. Biot's respirations
2. Kussmaul's respirations
3. Hyperpneic respirations
4. Cheyne-Stokes respirations

Question 2

The nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN?

1. As you age your blood pressure may go up, but it doesn't have to if your vessels are healthy.
2. If anyone's oral temperature is over 100 F, I'll let you know right away since that means they have a fever.
3. I always wait a good 30 minutes after returning the older client back to bed be-fore I count their pulse.
4. I watch the elderly client's stomach and count the number of times it rises when I am counting respirations.

Mollythedog · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 4
Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating pe-riods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern then reverses, breathing slows and becomes shallow, and the pattern climaxes in apnea before respiration resumes. Biot's respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. Kuss-maul's respirations are abnormally deep, regular, and increased in rate. Hyperpneic respirations are labored, increased in depth, and increased in rate (>20 breaths/min); they normally occur dur-ing exercise.

Answer to Question 2

ANS: 2
RAT: The temperature of older adults is at the lower end of the normal temperature range, 36 to 36.8 C (96.9 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally. Therefore tempera-tures considered within normal range sometimes reflect a fever in an older adult. The normal range for blood pressure is the same for older adults and younger people, while older adults de-pend more on accessory abdominal muscles during respiration than on weaker thoracic muscles, so observing the rise and fall of the abdomen would not be inappropriate. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate, so waiting 30 minutes would not be inappropriate.