While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Document the client's asymmetrical thoracic movement during inspiration.

Assist the client to a position that helps the client breathe more easily.

Provide the client an incentive spirometer to increase respiratory effort.

Encourage the client to continue to breathe deeply to expand the lungs.

Answer and Explanation

The Correct Answer is B

A. Documenting asymmetrical thoracic movement: While this might be a finding, it's not the most urgent action.

B. Assist the client to a position that helps the client breathe more easily. Sternocleidomastoid, trapezius, and abdominal muscle use: These muscles are accessory muscles that help with breathing when the diaphragm and intercostal muscles (primary muscles of respiration) are not functioning optimally. This use suggests laboured breathing. Priority action: The client's respiratory distress is the most pressing concern.

C. Incentive spirometer: This device helps improve lung expansion but is not the first-line intervention in this situation where the client is already struggling to breathe.

D. Encouraging deep breaths: This might further strain the respiratory muscles.

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Correct Answer is C

Explanation

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. While trapped air can be absorbed, crepitus can indicate underlying issues such as a pneumothorax or other trauma, so it should not be dismissed as insignificant.

B. Since this client has only a small area of crepitus, it probably is not a significant finding. The size of the area does not necessarily correlate with the severity of the underlying condition. Even a small area of crepitus should be investigated.

C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. This is the most accurate interpretation. Crepitus indicates the presence of air in the subcutaneous tissues, which is always abnormal and warrants further investigation.

D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately. While a chest x-ray can be part of the assessment, stating that a fractured rib "often" creates crepitus might be misleading. Crepitus can arise from other conditions, and a thorough assessment is needed before determining the exact cause.

A. Ask the client to describe the pain. B. Observe body language and movement. C. Identify effective pain relief measures. D. Provide a numeric pain scale.

Correct Answer is A

Explanation

A. Ask the client to describe the pain: This is the most crucial step. A good pain description can reveal characteristics like intensity, location, duration, and aggravating/relieving factors, all aiding in diagnosis.

B. Observe body language and movement: Nonverbal cues like grimacing, guarding (tensing muscles), or restlessness can indicate pain severity or location.

C. Identify effective pain relief measures: While this might be helpful later, it's not the primary way to assess pain quality initially.

D. Provide a numeric pain scale: Pain scales can be helpful for quantifying pain intensity, but a full description provides richer details.

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While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

Correct Answer is C

Explanation

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Correct Answer is A

Explanation

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