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. Osmosis: Osmosis refers to the movement of water across a membrane, not gases.
B. Active transport pump: Gas exchange does not require energy; it is a passive process, not active transport.
C. Filtration: Filtration is driven by hydrostatic pressure and is more relevant to kidneys and capillary exchange of fluids.
D. Diffusion: Diffusion is the passive movement of gases from an area of higher concentration to an area of lower concentration-how O₂ and CO₂ exchange occurs across the alveolar-capillary membrane.
Correct Answer is B
Explanation
A. Due to contraction of the trapezius muscle: Not involved in normal breathing.
B. Referred to as ventilation (breathing): Correct; ventilation is the process of moving air in and out of the lungs.
C. Due to relaxation of the diaphragm and intercostal muscles: Only exhalation is passive due to relaxation.
D. Caused by contraction and relaxation of the bronchiolar smooth muscle: Regulates airflow, not breathing movements.
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