Which finding requires the nurse to assess immediately because it may indicate compromised breathing?
Correct answer: C. New use of accessory muscles during breathing
- A. Respiratory rate of 18 per minute with clear speech
- B. Mild thirst after walking to the bathroom
- C. New use of accessory muscles during breathing
- D. Dry skin after spending time in a warm room
Explanation
New use of accessory muscles indicates increased work of breathing and possible respiratory compromise, so breathing assessment is the priority. The other findings do not by themselves suggest an immediate airway or breathing threat.
Report an error
The more specific you are, the faster it gets fixed. A source beats an opinion.
Prefer email? support@testustad.com
About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
Practise Nursing Process and Health Assessment
50 free Nursing Process and Health Assessment MCQs from Fundamentals of Nursing, each with the correct answer and an explanation. Unlimited attempts, no account needed.
Discussion
Stuck on an option, or know a faster way to get there? Ask or explain it here.
No comments yet. Be the first to explain this one.
Exams that ask Fundamentals of Nursing questions like this
Fundamentals of Nursing is on 9 papers prepared for on TestUstad, and all of them draw the same bank, so this question is worth knowing for every one of them.
More Nursing Process and Health Assessment questions
A nurse finds that a patient's expected outcome has not been achieved by the stated time. What is the most appropriate next action?
A patient speaks only a language the nurse does not understand. Which action supports the most accurate health assessment?
Which statement correctly describes a risk nursing diagnosis?
Which sequence correctly shows the main steps of the nursing process?
A patient reports severe abdominal pain, but the facial expression and vital signs do not support the report. What should the nurse do first?
Which assessment approach is most appropriate for a patient attending a clinic for the first time with several health concerns?