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 C
Explanation
A. Pharynx: Transports air but is not primarily responsible for warming/moistening.
B. Larynx: Functions in voice production and airway protection.
C. Nostrils/nares: Correct; nasal passages warm, moisten, and filter the air.
D. Alveoli: Site of gas exchange, not air conditioning.
Correct Answer is B
Explanation
A. Yearly chest x-rays- this detects disease but does not prevent it.
B. Don’t smoke or quit smoking- smoking is the most significant modifiable risk factor for COPD and lung cancer.
C. Daily exercise- while beneficial for overall health, it does not prevent lung disease as effectively as avoiding smoking.
D. Healthy diet- good nutrition supports health but is less specific for preventing lung diseases.
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