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 B

Explanation

A. Explaining the exam: Preschool-aged children might not fully understand the need for an exam, and this might not alleviate their anxiety.

B. Talking to parent and focusing on toy: This strategy prioritizes calming the child first. Talking to the parent helps gather information while the nurse gradually gains the child's trust by acknowledging their toy. This can create a more positive and collaborative environment.

C. Completing assessment while crying: This can be stressful for the child and might hinder an accurate assessment.

D. Requesting extra staff: While additional support might be helpful, the initial approach should focus on building rapport with the child.

A. Conduct an assessment of functional capacity and environmental hazards. B. Distinguish between symptoms caused by disease and those due to aging. C. Obtain a medication history including prescription and non-prescription drugs. D. Emphasize the need to place advance directives in the medical record.

Correct Answer is C

Explanation

A. Functional capacity: While important for older adults, it's not the most pressing concern during this routine follow-up exam.

B. Distinguishing symptoms: This is an ongoing process, but not the most critical element for this visit.

C. Obtain a medication history including prescription and non-prescription drugs. Cataract surgery often involves medication changes or new medications to prevent infection or manage other post-operative needs. An updated medication history helps identify potential interactions or side effects.

D. Advance directives: While important for all adults, it might not be the most urgent topic for this specific follow-up exam focused on managing existing conditions and potential post-surgical medications.

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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

A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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