Final answer:
The nurse should immediately auscultate for the absence of breath sounds in the lung periphery, as the abnormal chest wall moving in during inspiration and out during expiration can indicate serious conditions such as pneumothorax, hemothorax, or pleural effusion.
Step-by-step explanation:
When a patient's chest wall moving in during inspiration and out during expiration, which is opposite of the normal movement, this is referred to as paradoxical breathing and may indicate a serious underlying condition. The nurse should perform additional assessments immediately to ensure patient safety and identify any potential issues.
Given the abnormal chest wall movement, the immediate action the nurse should take is to auscultate for absence of breath sounds in the lung periphery. This will help determine if there is decreased or absent airflow to areas of the lungs, which could indicate a pneumothorax, hemothorax, or pleural effusion. Breath sounds are normally present and should include bronchial, bronchovesicular, and vesicular sounds; their absence could be a sign of a significant respiratory problem requiring immediate attention.
If the patient exhibits any signs of respiratory distress or if breath sounds are absent, immediate intervention may be necessary, which could include emergency medical treatment or further diagnostic testing such as a chest radiograph to visualize the potential causes of the abnormal chest wall movement and auscultation findings.