The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?
Remind the client to keep light pressure on the abdomen and cough after fully exhaling.
Confirm that the breathing technique was correct but hand pressure is not necessary.
Document that the client successfully demonstrated the diaphragmatic breathing technique.
Demonstrate how to expand the abdomen while inhaling and let it relax while exhaling.
The Correct Answer is D
Choice A reason: Keeping pressure on the abdomen and coughing is incorrect for diaphragmatic breathing, which enhances lung expansion, not airway clearance. Coughing is for post-drainage. The client’s incorrect technique (abdominal expansion on exhalation) requires correction, as this reverses mechanics, reducing ventilation efficiency in conditions like COPD.
Choice B reason: The client’s technique is incorrect, expanding the abdomen on exhalation, not inhalation, reducing diaphragmatic efficacy. Confirming it as correct is wrong, as it impairs lung expansion. Demonstrating proper technique corrects the error, ensuring effective breathing to improve oxygenation, addressing the physiological need for ventilation.
Choice C reason: Documenting success is inaccurate, as the client’s technique is reversed, expanding the abdomen on exhalation. Diaphragmatic breathing requires inhalation expansion to lower the diaphragm, increasing lung capacity. Correcting the technique via demonstration ensures proper mechanics, not documenting an ineffective method that hinders ventilation.
Choice D reason: Demonstrating proper diaphragmatic breathing corrects the client’s error of exhalation expansion. Inhaling expands the abdomen via diaphragmatic descent, increasing tidal volume; exhaling relaxes it. This optimizes ventilation, addressing the need for effective breathing in conditions requiring enhanced lung function, ensuring the client learns the correct technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Showing the client how to clean assumes cognitive capacity impaired in schizophrenia, where psychosis or disorganized thinking drives behaviors like fecal smearing. This may reflect delusions, not a lack of cleaning knowledge. Escorting the client out prioritizes hygiene and safety, allowing psychiatric assessment over teaching in an acute situation.
Choice B reason: Assisting with cleaning risks reinforcing the behavior and exposes both to pathogens like E. coli in feces. Schizophrenia may impair compliance or understanding. Escorting the client out ensures safety and hygiene, enabling evaluation of psychotic triggers, making this less appropriate than removing the client from the situation.
Choice C reason: Escorting the client out prevents further pathogen exposure, as feces carry infection risks (e.g., gastroenteritis). In schizophrenia, smearing may stem from psychosis, requiring psychiatric evaluation. This action ensures hygiene and safety, allowing assessment of underlying mental health issues, addressing the behavior’s root cause effectively.
Choice D reason: Explaining that feces belong in the toilet assumes rational understanding, impaired in schizophrenia due to disorganized thought or delusions. This behavior likely reflects psychosis. Escorting the client out prioritizes hygiene and safety, followed by psychiatric intervention, making explanation less effective than immediate removal from the contaminated area.
Correct Answer is A
Explanation
Choice A reason: Persistent pain after Herpes zoster suggests postherpetic neuralgia (PHN), a neuropathic condition from varicella-zoster virus damaging sensory nerves. Assessing pain intensity, location, and characteristics guides treatment with analgesics or anticonvulsants like gabapentin. This step differentiates PHN from other causes, ensuring targeted therapy to alleviate nerve pain and improve quality of life.
Choice B reason: Checking shingles vaccination status is irrelevant for current pain, as the client already had Herpes zoster. Vaccination prevents initial infection but does not treat PHN, which results from nerve damage during active infection. Pain assessment is critical to address neuropathic symptoms caused by viral-induced sensory nerve dysfunction, making this less urgent.
Choice C reason: A mental status exam evaluates cognition but is not indicated for PHN, a physiological condition from nerve damage, not a cognitive issue. Pain is neuropathic, driven by damaged sensory neurons, not psychological factors. Assessing pain directly addresses the client’s complaint, guiding treatment for nerve-related discomfort, making this action inappropriate.
Choice D reason: Teaching about phantom pain is incorrect, as phantom pain occurs post-amputation, not after shingles. PHN involves persistent nerve pain in the affected dermatome due to viral nerve damage. Misdiagnosing this could delay proper management, as pain assessment is needed to confirm PHN and initiate therapies like gabapentin, not phantom pain education.
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