Care Manager Certification Practice Exam

Which observation would alert a nurse to prioritize an immediate assessment for a hospice client?

1. Calm demeanor

2. Newly developed fever

3. Cheyne-stokes breathing

4. Regular heart rate

The correct answer is: Cheyne-stokes breathing

In the context of hospice care, Cheyne-Stokes breathing is an important indicator that requires immediate attention and assessment. This type of breathing pattern is characterized by fluctuating periods of deep, rapid breathing followed by periods of apnea. It often indicates a critical change in a patient's condition, such as altered levels of consciousness or impending death. Observing this breathing pattern can signal severe underlying issues, such as declining cardiac function or worsening respiratory failure, which necessitate prompt reassessment and possible intervention. While calm demeanor, newly developed fever, and a regular heart rate can also be significant observations, they do not typically indicate the same level of urgency as Cheyne-Stokes breathing. A calm demeanor might suggest stability, a newly developed fever may require monitoring but does not directly indicate an impending crisis, and a regular heart rate can be a reassuring sign of cardiovascular stability. Therefore, the presence of Cheyne-Stokes breathing stands out as the priority requiring immediate assessment in a hospice client.