Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne-Strokes respirations. Cheyne-strokes respirations are:

Correct Answer: A

Rationale: The correct answer is A: A progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing where respirations gradually increase in depth and rate, then decrease to the point of apnea before starting the cycle again. This pattern is often seen in clients with neurological issues such as cerebrovascular accidents affecting the brainstem. Choice B is incorrect because Cheyne-Stokes respirations do not have abrupt pauses between each breath. Choice C is incorrect as it describes irregular breathing without the characteristic pattern of increasing and decreasing respirations. Choice D is incorrect because Cheyne-Stokes respirations are not shallow but rather have a pattern of progressively deeper breaths.

Correct Answer: D

Rationale: The correct answer is D: The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem). This client should be assessed first because atrial fibrillation can lead to serious complications like stroke or heart failure. Assessing this client allows for prompt intervention to stabilize the heart rhythm. Choice A can be ruled out as the client's vital signs are stable and the condition has been present for 2 days. Choice B should be assessed next due to the critically low blood pressure, but the client with atrial fibrillation takes priority. Choice C, although receiving heparin, does not have an acute condition like atrial fibrillation that requires immediate attention.

Correct Answer: D

Rationale: The correct answer is D because after receiving a subarachnoid block, the client should remain supine for the specified time to prevent complications like a sudden drop in blood pressure. This position helps maintain proper blood flow to the brain and spinal cord. A is incorrect because maintaining hydration is important postoperatively. B is incorrect as there is no specific reason to avoid milk products. C is incorrect as blood in urine is not a common complication of a subarachnoid block and would not be the most important instruction at this time.

Correct Answer: C

Rationale: The correct answer is C: Deep vein thrombosis (DVT) due to immobility of the ipsilateral side. After a stroke, immobility can lead to blood pooling in the deep veins, increasing the risk of DVT. This can cause swelling in the affected limb. Choices A and B do not directly relate to swelling post-stroke. Choice D is not relevant to the situation described. Therefore, the correct choice is C due to the increased risk of DVT from immobility post-stroke.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.