The nurse is caring for an unconscious patient. What should the ...

[stevenposner]

The nurse is caring for an unconscious patient. What should the nurse expect to be prescribed for this patient when the cough reflex disappears?
 
  1. continuous pulse oximetry instead of intubation
  2. frequent suctioning with a tonsil-tip suction device
  3. close observation as the patient is fed
  4. intubation and mechanical ventilation

Question 2

The nurse notes that a patient with damage to the diencephalon region of the cerebrum is demonstrating a breathing pattern where regular periods of deep, rapid breathing are followed by periods of apnea.
 
  How should the nurse document this breathing pattern?
  1. Cheyne-Stokes respirations
  2. apneustic respirations
  3. neurogenic hyperventilation
  4. ataxic respirations

[kardosa007]

Answer to Question 1

Correct Answer: 4
This patient is at risk for impaired airway and aspiration. Oximetry would be done in addition to intubation and mechanical ventilation. Frequent oropharyngeal suctioning will not adequately protect the airway and the suctioning will cause hypoxia. No unconscious patient should be fed food or fluids.

Answer to Question 2

Correct Answer: 1
Cheyne-Stokes respirations are a change in breathing pattern, alternating regular periods of deep, rapid breathing with periods of apnea, and are seen in many patient conditions in the clinical setting. Apneustic respiration is a term used to describe an abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release. Neurogenic hyperventilation is hyperventilation associated with brain or spine injury. Ataxic respirations are shallow, irregular respirations associated with damage to the medullary respiratory center.