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. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.

B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.

C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.

D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.

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

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

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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