While providing care for a patient with asthma, the nurse notes the patient's shoulders are rising with each breath. What should the nurse realize this action represents?
a. Hyperinflation of the chest
b. The use of accessory muscles to aid breathing
c. Shoulder muscle fatigue related to difficulty breathing
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. C. Fatigued muscles would contract less, not more, making the shoulders rise. A. Hyperinflation can occur with respiratory disease but does not cause shoulders to rise. D. Breathing exercises include diaphragmatic and pursed-lip breathing, not raising the shoulders.
You might also like to view...
A student of nursing history understands Nightingale's use of the term "art" when describing nursing as having what context?
a. Care activities that were driven by experience and intuition b. Little scientific knowledge on which to base most nursing actions c. Nursing roles that were fluid and defined by context and environment d. Patient preferences dictating nursing actions when providing care
The nurse is assessing a client and confirms the presence of galactorrhea. The nurse understands that this finding is:
1. suggestive of endocrine disorders. 2. may indicate a malignancy. 3. probably an infection. 4. usually indicative of lactation.
A restaurant patron sitting at the next table begins to choke. The patron yells, "I'm choking! I can't breathe!" The first responder should:
a. initiate the Heimlich maneuver imme-diately. b. strike the victim sharply between the sca-pulae. c. encourage him to keep coughing and deep breathe. d. offer him a small sip of fluid.
The nurse teaches a class about medication used during pregnancy to pregnant women. The nurse determines that additional instruction is required when a patient makes which response?
1. "The baby can only be harmed by medications during the first trimester." 2. "It is important to not take over-the-counter (OTC) drugs during my pregnancy." 3. "Exposure to teratogens can result in my baby's death or in malformations." 4. "If I breastfeed my baby, drugs can come through my breast milk."