Advanced Patient Assessment Practice Exam

Which assessment indicates a need for respiratory intervention?

1. Normal SpO2 levels

2. Shallow breathing

3. Patient comfort

4. Accessory muscle use

The correct answer is: Accessory muscle use

The assessment indicating a need for respiratory intervention is the use of accessory muscles. When a patient begins to engage accessory muscles for breathing, it typically suggests that the primary muscles of respiration are insufficient to meet the body's oxygen demands. This compensatory mechanism often occurs in conditions of respiratory distress, such as asthma, COPD, or pneumonia. Accessory muscle use can manifest as visible contractions of muscles in the neck, chest, and abdomen, which is a direct indication that the patient is struggling to breathe effectively. This sign highlights an increased work of breathing, necessitating prompt evaluation and potential respiratory intervention to relieve the distress and optimize the patient’s oxygenation. In contrast, normal SpO2 levels suggest adequate oxygenation without the need for immediate intervention. Shallow breathing could also imply inadequate ventilation but may not always indicate a critical need for intervention depending on the clinical context. Patient comfort is also a subjective assessment that may not directly correlate with respiratory needs; a patient can be comfortable while still requiring intervention based on other signs. Thus, the use of accessory muscles is a clear indicator of a potential respiratory emergency and the need for immediate intervention.