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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Standard precautions:
Standard precautions are the basic level of infection control and should be used for all patient care. These precautions include practices like hand hygiene, the use of personal protective equipment (PPE), and safe injection practices.
B. Airborne precautions:
These precautions are used to prevent the transmission of infectious agents that are spread through the air. In the case of tuberculosis (TB), which is caused by Mycobacterium tuberculosis, airborne precautions are necessary to reduce the risk of airborne transmission.
C. Contact precautions:
Contact precautions are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. Examples include Clostridium difficile infection and multidrug-resistant organisms. These precautions involve the use of PPE and may include patient placement in a private room.
D. Droplet precautions:
Droplet precautions are used when a patient is known or suspected to be infected with pathogens that are transmitted by respiratory droplets. Examples include influenza and certain types of bacterial meningitis. These precautions include placing the patient in a private room and using PPE.
Correct Answer is C
Explanation
A. Kyphosis and clubbing of the fingers:
Kyphosis refers to an excessive forward curvature of the spine, which is not directly related to diminished breath sounds. Clubbing of the fingers is often associated with chronic respiratory conditions, but it is not directly linked to the finding of diminished breath sounds.
B. Dyspnea and hypoxemia:
Dyspnea (shortness of breath) and hypoxemia (low oxygen levels in the blood) are common symptoms in COPD, but diminished breath sounds may indicate an additional concern, such as pneumothorax or other complications.
C. Sepsis and pneumothorax:
Diminished breath sounds can be a sign of pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse. Sepsis is a risk in clients with COPD due to the potential for respiratory infections. Monitoring for these complications is crucial.
D. Bradypnea and pursed-lip breathing:
Bradypnea (slow breathing) and pursed-lip breathing are coping mechanisms that individuals with COPD may use to manage their breathing difficulties. While they are relevant in the context of COPD, they are not directly associated with the finding of diminished breath sounds.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today