The nurse assesses the client in respiratory distress and notes that the client has see-saw respirations with the chest and abdomen alternately rising, blue discoloration of the fingertips, and noisy difficult respirations
How would the nurse describe the client's condition when calling the health care provider?
1. Client is tachypneic with costal breathing and cyanosis.
2. Client is bradycardic with diaphragmatic breathing and cyanosis.
3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic.
4. Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.
Correct Answer: 3
The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the client's pulse is unknown.
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