A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

Diaphragmatic breathing

Controlled breathing

Pursed-lip breathing

Use of accessory muscles

Answer and Explanation

The Correct Answer is D

A. Diaphragmatic breathing:

Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.

B. Controlled breathing:

Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.

C. Pursed-lip breathing:

Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.

D. Use of accessory muscles:

The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.

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Correct Answer is B

Explanation

A. International normalized ratio (INR):

INR is a test used to monitor the effectiveness of anticoagulant therapy, particularly drugs like warfarin. It measures the time it takes for blood to clot. It's not directly related to assessing heart failure but is more associated with monitoring anticoagulation status.

B. Brain natriuretic peptide (BNP):

BNP is a peptide released by the heart in response to increased pressure and volume in the heart, often seen in heart failure. Elevated BNP levels can indicate the presence of heart failure. It's a useful diagnostic marker for heart failure.

C. Troponin:

Troponin is a protein released into the blood when there is damage to the heart muscle, usually during a heart attack. It is not specific to heart failure but is commonly used to diagnose myocardial infarction (heart attack).

D. Creatinine:

Creatinine is a waste product that comes from the normal wear and tear on muscles. While elevated creatinine levels can be seen in conditions affecting kidney function, it's not a direct marker for assessing heart failure. However, kidney function is often evaluated in conjunction with heart failure assessments.

A. The client now has developed a myocardial infarction B. The client has developed Prinzimetal’s angina. C. The client now has stable angina. D. The client now has unstable angina.

Correct Answer is D

Explanation

A. The client now has developed a myocardial infarction:

A myocardial infarction (heart attack) is characterized by prolonged ischemia leading to damage or death of heart muscle cells. While the symptoms described could be concerning for a heart attack, the term "myocardial infarction" would typically imply a more sustained and severe ischemic event.

B. The client has developed Prinzmetal's angina:

Prinzmetal's angina, also known as variant angina, is characterized by chest pain that usually occurs at rest and is caused by vasospasm of the coronary arteries. The given scenario does not specifically describe the typical characteristics of Prinzmetal's angina.

C. The client now has stable angina:

Stable angina typically follows a predictable pattern and is relieved with rest and/or nitroglycerin. However, the scenario describes a change in the usual pattern of chest pain.

D. The client now has unstable angina:

Unstable angina is characterized by a change in the usual pattern of stable angina, often occurring at rest or with minimal exertion and not relieved by usual measures. This option seems to align with the information provided.

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A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has signs and symptoms of heart failure. Which of the following diagnostic tests is appropriate to assess the patient’s heart failure?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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