When assessing a client with respiratory distress, which finding would alert the nurse to the severity of the condition?

The presence of accessory muscle use is a significant indicator of the severity of respiratory distress. When a client is experiencing difficulty breathing, the body may recruit additional muscles to assist with respiration. This includes muscles in the neck and shoulders, which are not typically used in normal breathing. The use of these accessory muscles suggests that the client is working harder to breathe and is likely facing a more severe respiratory compromise. This finding can indicate that the body is struggling to obtain adequate oxygenation, highlighting a critical need for timely intervention.

In assessing a client's condition, while factors like lip color, respiratory rate and rhythm, and level of consciousness are important, they do not directly demonstrate the physiological effort being exerted to breathe as clearly as accessory muscle use does. For instance, while cyanosis of the lips can indicate inadequate oxygen levels, it may not reflect the immediate effort the client is making. Respiratory rate and rhythm can vary for different reasons, and a change in level of consciousness might reflect a range of issues beyond just respiratory distress, including neurological problems. Thus, accessory muscle use stands out as a distinct and telling sign of severe respiratory distress.