Which will the nurse assess when evaluating breathing in a patient suspected of having a thoracic trauma? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Jugular vein distention
2. Symmetry of chest movement bilaterally
3. Chest movements that rise and fall with breathing effort
4. Respiratory rate, pattern, and effort
5. Peripheral skin coloring
1,2,3,4
Rationale 1: Jugular vein distention will increase when chest pressure rises with displacement or fluid buildup in which the heart must work harder to circulate the blood and perfuse tissues that are hypoxic.
Rationale 2: Chest movement symmetry will be assessed in the patient with thoracic trauma.
Rationale 3: Chest movements that rise and fall with breathing will be assessed in the patient with thoracic trauma.
Rationale 4: Respiratory rate, pattern, and effort will be assessed in the patient with thoracic trauma.
Rationale 5: Skin coloring is a circulation issue, not a breathing issue.
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