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 A
Explanation
A. Diaphragm: The diaphragm is a dome-shaped muscle that contracts and flattens during inhalation, creating negative pressure to draw air into the lungs.
B. Pectoris minor: The pectoralis minor assists with deep or labored breathing but is not the primary muscle of inhalation.
C. Pectoris major: This chest muscle plays a role in arm movement and may assist minimally in labored breathing.
D. Intercostals: The intercostal muscles assist with breathing but are secondary to the diaphragm.
Correct Answer is B
Explanation
A. A collection of excess fluid within the intrapleural: This describes a pleural effusion, not orthopnea.
B. Difficulty in breathing that is relieved by sitting upright: This is the definition of orthopnea, commonly seen in conditions like heart failure.
C. A bluish color of the skin induced by hypoxemia: This describes cyanosis, not orthopnea.
D. A lung infection like pneumonia: Pneumonia is a specific infection, not a description of breathing difficulty in certain positions.
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