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. Grapelike sacs located very close to pulmonary capillaries: This correctly describes the structure of alveoli.
B. Located within the lungs: Alveoli are indeed located in the lungs.
C. Primarily concerned with gas exchange: Alveoli are the main site of gas exchange in the lungs.
D. Contain smooth muscle: Alveoli do not contain smooth muscle; this is a feature of bronchi and bronchioles.
Correct Answer is ["A","B","D"]
Explanation
A. Pharynx: The pharynx (throat) is part of the upper respiratory tract and functions as a passageway for both air and food.
B. Nasal cavity: The nasal cavity is the main entryway for inhaled air and is part of the upper respiratory system.
C. Bronchial tree: The bronchial tree is part of the lower respiratory system, beginning with the bronchi and branching into bronchioles.
D. Larynx: The larynx (voice box) is part of the upper respiratory system; it connects the pharynx to the trachea.
E. Trachea: The trachea (windpipe) is part of the lower respiratory system.
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