Medical Surgical Pneumonia #5
The nurse assesses a client with pneumonia after the unlicensed health assistive personnel reports the client is having chest pain. The nurse determines the client may have pleuritic chest pain based on which finding?
- Rapid, shallow, painful respirations.
This answer is not correct because rapid shallow respirations are not typically associated with pleurisy. This type of breathing is typically a manifestation of metabolic acidosis as the client is attempting to blow off excess CO2.
- Coughing that triggers muscle spasm.
This answer is not correct because coughing that triggers muscle spasms is not associated with pleurisy. Pleurisy affects the pleural layers as opposed to the respiratory muscles.
- Chest pain that worsens on inspiration.
This answer is correct because pleuritic chest pain is pain that usually worsens on inspiration because of friction between the pleural layers. Pain occurs on inspiration and expiration due to chest wall movement; however, it is worse on inspiration.
- Complaints of mild but constant aching in the chest.
This answer is not correct because the pain associated with pleurisy is not mild and constant. It increases greatly during inspiration as the inflamed pleural layers grate against each other. The pain during inspiration is usually very sharp as opposed to achy.
The focus of this question is determining which clinical manifestation is most closely associated with pleurisy. Pleurisy is an inflammation of the pleural layers which causes pain especially during inspiration when the layers are grating against each other.
Pleuritis is an inflammation of the membranes that surround the lungs and line the chest cavity. These layers grate against each other during inspiration causing chest pain that worsens upon inspiration. The pain is usually described by clients as a dull ache that worsens upon inspiration.
Test Taking Tip
Look at keywords in the stem of the question. The question is specifically referring to chest pain and answer choice 3 is the only option that has the exact words “chest pain” included.