Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position (sitting or standing leaning forward and supporting the upper body with hands on knees or other surfaces). peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. Cyanosis: bluish discolouration of the skin due to poor circulation (e.g.Age: the patient’s approximate age is helpful when considering the most likely underlying pathology, with younger patients more likely to have diagnoses such as asthma or cystic fibrosis (CF) and older patients more likely to have chronic obstructive pulmonary disease (COPD), interstitial lung disease or malignancy.Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology: Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.You might also be interested in our premium collection of 1,000+ ready-made OSCE Stations, including a range of clinical examination stations ✨ General inspection Clinical signs I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.ĭ- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client. The other options are inappropriate because:Ī- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.Ĭ- "You really scared me. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.ĭ- Repeating auscultation after asking the client to breathe deeply and cough may help the nurse gather more information about the client's lung sounds, but it does not address the immediate need for improving lung expansion and oxygenation in the presence of crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.Ĭ- Preparing to administer antibiotics is not the first intervention for crackles. The other interventions are not appropriate for crackles in the left lower lobe:ī-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Placing the client on bed rest in a semi-Fowler position helps to improve lung expansion and oxygenation by reducing the pressure on the diaphragm, promoting optimal lung ventilation, and facilitating drainage of fluid from the affected area of the lung. Answer and Explanation The Correct Answer is AĮxplanation: Crackles are abnormal lung sounds that may indicate the presence of fluid or mucus in the lungs.
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