While providing care for a patient with asthma, the nurse notes the patient's shoulders are rising with each breath. The nurse recognizes this action most likely represents which of the following?
a. Shoulder muscle fatigue related to difficulty breathing
b. The use of accessory muscles to aid breathing
c. Hyperinflation of the chest
d. Effective use of a breathing exercise to increase ventilation
ANS: B
Use of the sternocleidomastoid (accessory) muscles causes the shoulders to rise during labored inspiration. Fatigued muscles would contract less, not more, making the shoulders rise. Hyperinflation can occur with respiratory disease but does not cause shoulders to rise. Breathing exercises include diaphragmatic and pursed-lip breathing, not raising the shoulders.
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