CNA Certification (Written Exam)Basic Nursing SkillsMedium
A nurse aide is observing a resident and notes that their breathing is labored, shallow, and they are using accessory muscles to breathe. This observation should be reported immediately as it indicates:
- ASigns of respiratory distress.
- BA normal variation in breathing patterns.
- CTemporary shortness of breath from exertion.
- DMild anxiety that will resolve on its own.
Show answer & explanationAnswer & explanation
Correct answer: A. Signs of respiratory distress.
Labored, shallow breathing with the use of accessory muscles (neck and shoulder muscles) are classic signs of respiratory distress. This indicates the resident is struggling to breathe and requires immediate nursing assessment.
Why the other options are wrong
- B. Labored, shallow breathing with accessory muscle use is an abnormal and concerning finding, not a normal variation.
- C. While exertion can cause temporary shortness of breath, the use of accessory muscles and labored breathing suggest a more serious, ongoing issue.
- D. These physical signs are indicative of a physiological problem, not merely mild anxiety, though anxiety can exacerbate respiratory issues.
Signs of Respiratory Distress
Clinical indicators that a person is having difficulty breathing and is not getting enough oxygen.
- Labored breathing (dyspnea)
- Shallow respirations
- Use of accessory muscles (neck, shoulder, abdominal)
- Nasal flaring, grunting (especially in children)
- Cyanosis (bluish discoloration)
- Increased respiratory rate
Memory trick: Struggling to Breathe? Look for the '3 S's': Struggle, Shallow, Shoulder muscles!