The nurse uses inspection when performing a focused assessment of the respiratory system of a client complaining of cold symptoms. When the client asks the nurse why the nurse is watching the client breathe, the nurse should reply:
1. "I am checking the skin color of the chest."
2. "I am checking to make sure both sides expand equally."
3. "I am listening to hear air movement through the larynx."
4. "I am timing your inspirations."
Answer: 2
1. The skin color on the chest will match the rest of the body.
2. Unequal chest expansion could indicate pathology.
3. The nurse listens to air in the upper airway by placing the stethoscope gently on the neck.
4. The nurse will not usually time inspiration unless the client has extreme lung pathology.
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