You notice that a client's sternocleidomastoid muscle (an accessory respiratory muscle) is contracting with respiration while the patient is at rest. What should the nurse conclude based on this observance?
The patient has hypotension
The patient is breathing normally, using the normal muscles of inspiration and expiration.
The patient is having difficulty breathing
The patient has hypertension
The Correct Answer is C
A. The patient has hypotension: Hypotension does not directly cause use of accessory muscles.
B. The patient is breathing normally, using the normal muscles of inspiration and expiration: Normal breathing uses the diaphragm and intercostals, not accessory muscles like the sternocleidomastoid.
C. The patient is having difficulty breathing: Use of accessory muscles at rest indicates respiratory distress or difficulty in breathing.
D. The patient has hypertension: Hypertension is not directly related to accessory muscle use during breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. is responsible for the pumping of O2 from the alveoli into the pulmonary capillaries: gas exchange occurs by diffusion, not nerve stimulation.
B. Is responsible for exhalation: exhalation is a passive process; phrenic nerve controls diaphragm contraction for inhalation.
C. Decreases thoracic volume: diaphragm contraction increases thoracic volume.
D. Causes the diaphragm to contract: the phrenic nerve innervates the diaphragm and stimulates its contraction for inhalation.
Correct Answer is ["A","C","D"]
Explanation
A. Trachea: The trachea is the beginning of the lower respiratory tract and conducts air to the bronchi.
B. Pharynx: The pharynx is part of the upper respiratory system.
C. Lungs: The lungs are the primary organs of the lower respiratory tract responsible for gas exchange.
D. Bronchial tree: The bronchial tree, including bronchi and bronchioles, is part of the lower respiratory system.
E. Larynx: The larynx is the uppermost structure of the lower respiratory system in some classifications but is more commonly considered part of the upper respiratory tract.
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