A nurse notes a client's intercostal muscles are pulling inwards and reports difficulty breathing. The nurse would document which of the following to describe this type of abnormal breathing pattern:

Orthopnea

Stridor

Retractions

Hyperventilation

Answer and Explanation

The Correct Answer is C

A. Orthopnea: Orthopnea describes shortness of breath when lying flat, not the visible inward pulling of chest wall muscles.

B. Stridor: Stridor is a high-pitched inspiratory sound from upper airway obstruction, not the visual chest wall retraction.

C. Retractions: Retractions describe inward movement of intercostal or suprasternal tissues during inspiration and indicate increased work of breathing or respiratory distress.

D. Hyperventilation: Hyperventilation is rapid, deep breathing (increased minute ventilation) and does not specifically describe inward chest wall movement.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Inform the client of what food is being offered with each spoon/forkful: Narrating each item and using an orientation method (e.g., clock-face placement) promotes independence, reduces anxiety, and helps the client safely identify foods.

B. Provide ground and pureed foods to reduce aspiration risk: Ground/pureed textures are used when there is a swallowing (dysphagia) risk; visual impairment alone does not require texture modification and could unnecessarily limit intake.

C. Ensure that the client is eating at brisk pace: Encouraging a fast pace may increase choking/aspiration risk and reduce enjoyment; allow an appropriate, unhurried pace.

D. Request a full liquid diet so the client can drink the meal: Full liquids are indicated for specific medical/swallowing reasons, not for visual impairment; this change is not needed solely because the client is visually impaired.

A. Bronchovesicular B. Wheezing C. Rales D. Bruit

Correct Answer is B

Explanation

A. Bronchovesicular: Bronchovesicular sounds are normal breath sounds heard over central airways and are not adventitious findings of bronchoconstriction.

B. Wheezing: Wheezes are high-pitched, musical sounds produced by airflow through narrowed airways and are commonly heard with bronchoconstriction (e.g., asthma).

C. Rales: Rales (crackles) are discontinuous sounds often associated with fluid in the alveoli (e.g., pulmonary edema, pneumonia), not bronchoconstriction.

D. Bruit: A bruit is an abnormal vascular sound heard over arteries and is unrelated to lung auscultation.

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A nurse notes a client's intercostal muscles are pulling inwards and reports difficulty breathing. The nurse would document which of the following to describe this type of abnormal breathing pattern:

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