When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem?
Syncope.
Acute pain.
Tetany.
Dyspnea.
The Correct Answer is D
Choice A Reason:
Syncope is incorrect. Syncope, or fainting, can occur in individuals experiencing severe respiratory distress or hypoxia. Pursed-lip breathing is often used as a technique to manage dyspnea and improve oxygenation, which can help prevent syncope by ensuring adequate ventilation and oxygen delivery to the body's tissues. However, syncope is not the primary concern associated with the observation of pursed-lip breathing; instead, it is a potential consequence of inadequate oxygenation.
Choice B Reason:
Acute pain is not directly related to the observation of pursed-lip breathing. Pursed-lip breathing is a technique used to manage dyspnea and improve ventilation efficiency in individuals with respiratory conditions such as chronic obstructive pulmonary disease (COPD) or asthma exacerbation. While pain can exacerbate respiratory distress in some cases, the primary focus when observing pursed-lip breathing is to assess and address respiratory status rather than pain management.
Choice C Reason:
Tetany is incorrect. Tetany, characterized by muscle spasms due to low calcium levels, is not directly associated with the observation of pursed-lip breathing. Pursed-lip breathing is a respiratory technique used to manage dyspnea and improve ventilation in individuals with respiratory conditions such as COPD or asthma. While respiratory distress can lead to various physiological responses, tetany is not a typical manifestation observed in individuals using pursed-lip breathing.
Choice D Reason:
Dyspnea is correct. Pursed-lip breathing is a technique often used by individuals with respiratory conditions to relieve shortness of breath and improve breathing efficiency. The primary reason for using pursed-lip breathing is to help alleviate dyspnea, or difficulty breathing, by promoting more effective exhalation and preventing airway collapse during expiration. Monitoring for dyspnea is crucial in this situation to assess the client's respiratory status, including the severity of breathing difficulty and any associated symptoms, and to guide further interventions to address the underlying cause of dyspnea. While syncope (fainting), acute pain, and tetany (muscle spasms due to low calcium levels) are potential concerns in certain clinical contexts, they are not directly associated with the observation of pursed-lip breathing. Therefore, dyspnea is the most relevant problem for the nurse to monitor in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
Wheal is correct. A wheal is a raised area of skin that is typically reddened and accompanied by itching. It contains fluid and is often associated with allergic reactions, insect bites, or hives.
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.
Correct Answer is D
Explanation
Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.
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