Chapter 15 - D'Amico/Barbarito Health & Physical Assessment in Nursing, 2/e

A 4-year-old child's respiratory rate is 30 per minute. The mother states, "That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute." Which of the following is the nurse's best response? a. "This is a normal finding for your child's age." b. "Your child is exhibiting a sign of a respiratory infection." c. "Your child requires further assessment." d. "Your child may simply be anxious."

A

As the nurse assesses the pregnant client she states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. The nurse realizes that the client's difficulty is related to: a. The fetus pushing the diaphragm upwards. b. Fatigue due to the pregnancy. c. Anxiety about her impending delivery. d. Contractions.

A

The client was brought to the Emergency Department. The nurse administered a breathing treatment for the client earlier. The nurse is preparing the client for a procedure. The nurse notes that the client is breathing in a shallow manner and the client's hands are trembling. Which of the following actions will help decrease the client's level of anxiety? a. The nurse should explain all procedures in a calm and reassuring voice. b. Request the immediate presence of the healthcare provider. c. Provide oxygen for the client. d. Postpone the procedure.

A

The nurse is examining an African American client. When compared to Caucasians, which of the following conditions is this client at a higher risk for developing? Select all that apply. a. Asthma b. Sarcoidosis c. Tuberculosis d. Obstructive sleep apnea (OSA) e. Chronic bronchitis

A, B, C, D

The nurse is preparing an educational program regarding Healthy People 2020. Which of the following pieces of information is important to include for caregivers of infants and young children? Select all that apply. a. "Infants should always be placed to sleep on their backs." b. "Children should be taught to wash their hands." c. "Caregivers should ensure that the children's toys are age-appropriate." d. "Parents should be educated about the importance of immunizations." e. "Caregivers should inspect the children's toys for small possibly inhalable parts."

A, B, C, D, E

The nurse is assessing a client with a severe left pleural effusion. Which of the following findings are expected? Select all that apply. a. Absent breath sounds on the left side b. Tracheal shift to the right c. Hyperresonance upon percussion. d. Bronchial breath sounds of the right side e. Pleural friction rub auscultated.

A, B, E a. Absent breath sounds on the left side b. Tracheal shift to the right e. Pleural friction rub auscultated.

While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. Which of the following conditions may produce this finding? Select all that apply. a. Atelectasis b. Chronic bronchitis c. Lobar pneumonia d. Pleural effusion e. Congestive heart failure

A, C, D a. Atelectasis c. Lobar pneumonia d. Pleural effusion

The nurse is preparing to auscultate a client's lungs. Which of the following breath sounds would be considered abnormal? Select all that apply. a. Crackles b. Vesicular c. Bronchovesicular d. Wheezes e. Bronchial

A, D a. Crackles d. Wheezes

During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This structure can be identified by using which of the following landmarks? a. Clavicle b. Sternum c. First rib d. Vertebral column

B

The client is 36 weeks pregnant. The nurse is assessing the client's respiratory system and finds that her respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which of the following is the nurse's best response? a. "You have developed asthma during your pregnancy." b. "During your last trimester, it is normal for you to feel short of breath and to have a faster respiratory rate." c. "I'm going to have to notify your healthcare provider right now about these findings." d. "You have been infected with tuberculosis."

B

The nurse documents that the client's respirations are shallow and rapid. The client's respiratory rate is 30 per minute. From this finding, the nurse is concerned the client is: a. Fatigued. b. Anxious. c. Normal. d. Bored.

B

The nurse is preparing to assess an elderly client with emphysema. Which of the following anatomical changes would the nurse expect to find in this client? a. Funnel chest b. Barrel chest c. Pigeon chest d. Scoliosis

B

During the assessment of a client's voice sounds, the nurse hears louder sounds over the client's right lower lobe. This finding would be consistent with: a. Atelectasis. b. Lobar pneumonia. c. Asthma. d. Pleural effusion.

B Rationale a: Voice sounds are decreased or absent over areas of atelectasis. Rationale b: Voice sounds are increased and clearer over areas affected by lobar pneumonia. Rationale c: Voice sounds are decreased or absent over areas of asthma. Rationale d: Voice sounds are decreased or absent over areas of pleural effusion.

A client is demonstrating a diminished ability to exhale. The nurse realizes this client is at risk for developing: a. Pleurisy. b. Congestive heart failure. c. Increased carbon dioxide levels. d. Reduced oxygen capacity.

C

A client with chronic bronchitis has been admitted to the hospital. The nurse inspects the client while assessing the client's respiratory system. Which of the following would be an expected finding? a. Fever b. Decreased respiratory rate c. Use of accessory muscles d. Dry cough

C

The nurse is assessing a 1-month-old infant's respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. The nurse recognizes that this finding is: a. A sign of severe respiratory distress. b. An indicator that the infant has developed pneumonia. c. A normal finding. d. An indicator that the infant has developed a pneumothorax.

C

The nurse is assessing the client. The nurse hears low-pitched, continuous respiratory sounds that have a snoring quality while auscultating the client's lungs. The nurse would correctly document these findings as which of the following? a. Rales b. Crackles c. Rhonchi d. Wheezes

C

The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions? a. Pneumonia b. Atelectasis c. Pneumothorax d. Pleural effusion

C

While the client sleeps, the nurse notes that the client's respirations periodically stop. This finding would be documented as: a. Tachypnea. b. Bradypnea. c. Apnea. d. Atelectasis.

C

During the assessment of a client's respiratory system, the nurse determines that the client's expiration phase is the same length as the inspiration phase. The client's respiratory rate is 14 per minute. The nurse would document this finding as: a. obstructive breathing. b. bradypnea. c. respiratory distress. d. normal.

D

The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which of the following terms would the nurse use to document this finding? a. Tachypnea b. Obstructive breathing c. Hypoventilation d. Cheyne-Stokes

D

The nurse is assessing the client's respiratory system. Which of the following methods will result in the most accurate assessment of the client's respiratory rate? a. The nurse should place a hand on the client's chest to count respirations accurately. b. The nurse should inform the client that the nurse is counting the client's respirations. c. The nurse should count only the respirations that are audible. d. The nurse should count the respirations in an unobtrusive manner without informing the client.

D

The nurse is caring for a teenager recently hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts for the client. The nurse intervenes and prevents which of the following items from being brought into the patient's room? a. Magazines b. Candy c. MP3 player d. Fresh flowers

D

The nurse is examining a client who has been diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured? a. 1 b. 5 c. 9 d. 12

D

The nurse is percussing the anterior chest of an elderly client. Which of the following would the nurse expect to find in this client? a. Flatness b. Dullness c. Tympany d. Hyperresonance

D

The nurse wants to assess the apex of a client's right lung. Which of the following locations should the nurse place the stethoscope to assess this area on the client? a. Intercostal space 6th rib near the sternum b. Intercostal space 4th rib near the axillary line c. Below the scapula d. Near the right clavicle

D

The nursing instructor is observing a student nurse assess the client's respiratory system. The student demonstrates proper technique for auscultation when moving the stethoscope: a. From base to apices of lungs. b. First up one side of the thorax, then up the other. c. First down one side of the thorax, then down the other. d. From side to side.

D

While assessing the client, the nurse notes that the client has a moist cough. The nurse would include which of the following questions in the focused interview? a. "Have you been losing weight?" b. "How long have you been sick?" c. "Are you wheezing?" d. "Are you coughing up any mucus or phlegm?"

D

The nurse is preparing to assess the client's respiratory system. Rank in order according to how the nurse should proceed. a. Auscultation b. Inspection c. Percussion d. Client survey e. Palpation

D, B, E, C, A Client survey Inspection Palpation Percussion Auscultation