The nurse is observing the respiratory effort of a client, and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select All That Apply

Thoracic muscle tenderness

Barrel Chest

Pectus excavatum

Atelectasis

Obstruction

Answer and Explanation

Correct Answer : D,E

A.   Thoracic muscle tenderness is not directly associated with intercostal retraction. Muscle tenderness may occur due to overuse or strain but does not cause the retraction of the intercostal spaces. It is more related to musculoskeletal issues rather than respiratory conditions.
B.   Barrel chest refers to an increased anterior-posterior chest diameter, often seen in chronic obstructive pulmonary disease (COPD) and emphysema. While barrel chest can indicate chronic lung conditions that might cause respiratory distress, it does not directly cause intercostal retraction.
C.   Pectus excavatum, or "funnel chest," is a congenital deformity where the sternum is depressed inward, giving the chest a sunken appearance. However, pectus excavatum itself does not directly cause retractions but can be associated with increased respiratory effort.
D.   Atelectasis refers to the collapse of part or all of a lung, leading to decreased lung volume. This condition often results in increased respiratory effort and can be associated with intercostal retractions as the body struggles to expand the collapsed lung areas and improve ventilation.
E.   Obstruction of the airways, such as from a foreign body, mucus plug, or severe bronchoconstriction, can lead to increased respiratory effort as the client tries to overcome the obstruction. This increased effort often results in visible signs of respiratory distress, including intercostal retraction.

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Correct Answer is A

Explanation

A. Scoliosis is characterized by an abnormal lateral curvature of the spine. This can result in an uneven shoulder height and an asymmetrical rib cage when viewed from the front or back. The spine may curve to the side, creating a noticeable "S" or "C" shape.
B. Lordosis, also known as hyperlordosis, is an excessive inward curvature of the lower back (lumbar spine). This condition makes the buttocks appear more prominent and the abdomen to protrude. The pelvis tilts forward, creating a pronounced curve in the lower back.
C. Pigeon chest, or pectus carinatum, is a condition where the chest protrudes outward, giving it a "pigeon-like" appearance. The sternum sticks out, creating a noticeable bulge in the center of the chest.

D. Kyphosis is characterized by an excessive outward curvature of the upper spine (thoracic spine), resulting in a hunchbacked or rounded appearance of the upper back. The back may appear rounded or hunched when viewed from the side.

A. The nurse should count the respirations in an unobtrusive manner without informing the client. B. The nurse should inform the client that they are preparing to count the client's respirations. C. The nurse should place a hand on the client's chest to count respirations. D. The nurse should count when the respirations are audible.

Correct Answer is A

Explanation

A. Counting respirations unobtrusively helps ensure the client does not alter their breathing pattern due to the awareness of being observed. This method is generally preferred because it provides a more accurate assessment of the client's normal respiratory rate.
B. If the client is informed that their respirations are being counted, they may unconsciously alter their breathing pattern due to nervousness or the desire to appear normal. This could result in an inaccurate assessment of their true respiratory rate.
C. Placing a hand on the client's chest can be helpful in assessing the depth and evenness of respirations. However, this method might cause the client to become aware of the assessment and could lead to a change in their breathing pattern.
D. Counting respirations only when they are audible can be problematic. Audible respirations are not always present and may not accurately reflect the client’s full respiratory rate. This method may miss periods of quiet breathing and thus provide an incomplete assessment of the respiratory rate.

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The nurse is observing the respiratory effort of a client, and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select All That Apply

Nursing Test Bank

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Which abnormality is depicted in the image below?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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