Jarvis CH#19 Thorax and Lungs

Palpable rhonchal fremitus indicates which condition?

Thick bronchial secretions

What are normal breath sounds?

In a normal air-filled lung, vesicular sounds are heard over most of the lung fields, bronchovesicular sounds are heard between the 1st and 2nd interspaces on the anterior chest, bronchial sounds are heard over the body of the sternum, and tracheal sounds are heard over the trachea.

Which description of hypercapnia is correct?

Increased carbon dioxide in the blood

The nurse hears a cracking sound like two pieces of leather rubbing together on auscultation and suspects which abnormality?

friction rub

Which assessment finding would the nurse associate with mycoplasma pneumonia?

hacking

Which structures would the nurse assess when looking at the mediastinum? Select all that apply.

heart, trachea, esophagus

What is Diaphoresis ?

is excessive sweating, which can be related to shortness of breath

A college student presents to the emergency room with complaints of a sudden, sharp pain on the right side and shortness of breath. The right side of the chest is not moving with inspiration. The patient's trachea is deviated toward the left; there is no tactile fremitus on the right. The nurse hears hyperresonant percussion sounds on the right and resonant sounds on the left. There are no breath sounds heard on the right. Which disorder would the nurse suspect?

pneumothorax

The nurse includes which actions when auscultating the anterior chest of a patient for breath sounds? Select all that apply.

Starts the auscultation at the apices in the supraclavicular areas Auscultates and listens for one full respiration in each location Completes the examination by auscultating down to the sixth rib

The nurse is caring for a child with acute epiglottitis. The child has a high-pitched, monophonic, inspiratory crowing sound. Which term would the nurse use to document this finding?

Stridor

Which is the end result of occasional sighing that punctuates normal breathing?

alveolar expansion

A young adult patient reports difficulty in breathing. Upon inspection, the patient is cyanotic, using accessory neck muscles to breathe, and audibly wheezing. Palpation reveals decreased tactile fremitus with hyperresonant sounds on percussion. Normal breath sounds are distant and hard to hear because of wheezing. The nurse suspects further testing will lead to which diagnosis?

asthma

Which changes take place during the process of inspiration? Select all that apply. 1. Diaphragm descends 2. Elastic recoil property acts 3. Intercostal muscles contract 4. Intrathoracic pressure decreases 5. Anteroposterior diameter decreases

1. Diaphragm descends 3. Intercostal muscles contract 4. Intrathoracic pressure decreases

Which statement is true regarding the right lung? 1. It is shorter than the left lung. 2. It has an upper and lower lobe. 3. It is narrower than the left lung. 4. Its lobes sit as horizontal bands.

1. It is shorter than the left lung.

Arrange the following steps to show the order in which lung development takes place from the embryonic stage to the birth of the infant.

1. Primitive lung bud emerges during fetal life. 2. Conducting airways develop as in the adult. 3. Surfactant is present in adequate amounts. 4. Lungs form about 70 million primitive alveoli. 5. Blood supply is detached from the placenta. 6. Blood gushes into the pulmonary circulation

How many thoracic vertebrae are present in the human body?

12 thoracic Vertebral column in general. The vertebral column usually consists of 33 vertebrae: 24 presacral vertebrae (7 cervical, 12 thoracic, and 5 lumbar) followed by the sacrum (5 fused sacral vertebrae) and the coccyx (4 frequently fused coccygeal vertebrae).

Which additional muscles are involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? Select all that apply. 1. Scaleni 2. Trapezii 3. Diaphragm 4. Sternomastoids 5. Intercostal muscle

1. Scaleni 2. Trapezii 4. Sternomastoids

Which structure separates the thoracic cavity from the abdomen? 1.Sternum 2. Diaphragm 3. Manubrium 4. Xiphoid process

2. Diaphragm

Which statement describes the structure of the lungs? 1. The lungs contain approximately 300 alveoli. 2. The right lung is shorter and wider than the left lung. 3. The trachea bifurcates at the level of T10 posteriorly. 4. The right lung has two lobes, and the left lung has three lobes

2. The right lung is shorter and wider than the left lung.

In which location would the nurse auscultate the highest point of the lung on the anterior side of the chest?

3 to 4 cm above the clavicle

Which amount of diaphragmatic excursion is considered normal?

3 to 5 cm

Which breath sounds are considered normal? Select all that apply. 1. Crackles 2. Wheezes 3. Bronchial 4. Vesicular 5. Bronchovesicula

3. Bronchial 4. Vesicular 5. Bronchovesicula

The nurse attributes the patient's regular breathing rate of eight breaths per minute to which condition? 1. Prolonged bed rest 2. Splinting of the chest 3. Overdose of stimulants 4. Drug-induced depression

4. Drug-induced depression

The nurse is aware that structures at which depth are able to be assessed with percussion?

5 to 7 cm

The nurse is assessing a newborn immediately after birth. The newborn has a heart rate of 105 with good respiratory effort. There is some flexion of the extremities and some resistance to extension. The newborn grimaces in response to a catheter in the nares. The body is pink and the extremities are pale. What is the Apgar score for the newborn? Record your answer using a whole number.

7.

Which assessment finding is expected in a patient with pneumonia?

A lag in the chest expansion

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease (COPD)? Select all that apply.

A. The neck muscles appear to be hypertrophied from overwork. D. The patient leans forward with the arms against the knees. E. The anteroposterior and transverse diameter are both equal.

Which statements are true about the pleura? Select all that apply.

A. Thin, slippery serous membrane C. Pleural cavity normally has negative pressure D. Lies between the lungs and the chest wall

Which patient population is most likely to be affected by scoliosis?

Adolescents

Which part of the lungs is assessed on the posterior chest?

All parts of the lower lobes

Which characteristics are included in the assessment of breath sounds? Select all that apply.

Amplitude Pitch Quality

Which abnormality would the nurse expect in a patient with kyphosis?

An exaggerated posterior curvature of the thoracic spine

An increase in tactile fremitus indicates

An increase in tactile fremitus indicates denser or inflamed lung tissue, which can be caused by diseases such as pneumonia.

Which finding would the nurse identify as normal when assessing the chest of an older adult patient?

An outward curvature noted in the thoracic spine

The nurse planning care for an older adult patient who had major abdominal surgery 1 day ago includes interventions to address which patient-specific risk factors for atelectasis? Select all that apply.

B. Decrease in the ability to cough C. Loss of protective airway reflexes E. Increase in the amount of secretions

Biot's respirations

Biot's respiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. It is named for Camille Biot, who characterized it in 1876

Which finding would the nurse document as normal after auscultation of a toddler's chest for breath sounds?

Bronchovesicular breath sounds in the peripheral lung fields

Which technique would the nurse use to assess for tactile fremitus?

By placing the palmar base of one hand to touch the patient's chest

Which posterior vertebral landmark is the most prominent spinous process?

Cervical 7

barrel chest

Chest appears as if held in continuous inspirstion, ribs appears to be horizontal in relation to the spine, anteroposterior diameter is equal to the transverse diameter

Which assessment finding would the nurse expect for a patient with chronic respiratory disease?

Clubbing of the distal phalanges

The nurse auscultates the patient's respirations and notes breath sounds similar to opening Velcro. Which term would the nurse use to document this finding?

Coarse Crackles

after open thoracic surgery, nurse notes a crackling sensation upon palpating the patient's chest wall. the nurse reports which condition to the provider?

Crepitus

Which term is used to document excessive sweating associated with shortness of breath? Diaphoresis Chronic dyspnea Two-pillow orthopnea Paroxysmal nocturnal dyspnea

Diaphoresis

While auscultating the chest, the nurse asks the patient to phonate a long "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears a long "aaaaa" sound. Which term would the nurse to document this assessment?

Egophony

The goblet cells of the lungs serve which purpose?

Entrap small particulate matter

The nurse is assessing a patient who reports a cough that always occurs in the daytime or early evening but subsides at night. What is the most probable cause for the cough?

Exposure to irritants at work

Which finding is a cause for concern after assessing a patient's respirations

Interspaces appear to be bulging during expiration

Which statement precisely describes the "angle of Louis"?

It is the articulation of the manubrium and the body of the sternum.

During the chest assessment of a patient, which reference line would the nurse note on the posterior chest wall?

Midspinal

The nurse learns in shift report that the patient has Biot's respirations. The nurse anticipates which assessment?

Normal breathing interrupted by apnea

Where would the nurse place the stethoscope to assess the patient's bronchial breath sounds?

Over the trachea and the larynx

Decreased tactile fremitus is consistent with which diagnosis?

Pleural effusion

The patient reports coughing up pink, frothy sputum. The nurse reports suspicion of which condition to the provider?

Pulmonary edema

6 minute walk test (6MWT)

Put a pulse oximeter on the patient's finger Conduct the test in a flat surfaces corridor Stop if oxygen saturation is less than 85%

Which respiratory assessment finding would the nurse report as abnormal for an adult patient?

Respiratory rate is 24 to 30 per minute.

Which assessment findings of the patient's anterior chest warrant further investigation? Select all that apply.

The patient breathes through pursed lips. The costal angle is greater than 90 degrees. The abdominal muscles indicate hypertrophy.

Which characteristics are consistent with pectus excavatum? Select all that apply.

The patient has a markedly sunken sternum. The condition is congenital, not symptomatic. The depression is more noticeable on inspiration.

Which assessment of the thorax and lungs of an infant requires further investigation?

The respiration causes marked retraction of the sternum.

Intercostal spaces are numbered based on which structures?

The ribs present above the spaces

Which statement describes the structure of the lungs?

The right lung is shorter and wider than the left lung.

The nurse counsels the pregnant patient to expect which changes in the respiratory system? Select all that apply.

The total circumference of the chest cage increases by 6 cm. There is a decrease in the vertical diameter of the thoracic cage. The patient has an increased awareness of the need to breathe.

The nurse is caring for an elderly patient. Which finding does the nurse associate with Cheyne-Strokes respiration?

There are periods of apnea in between normal breaths

A decrease suggests in tactile fremitus indicates

air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma.

which breath sounds are considered normal?

bronchial, vesicular, bronchovesicular

Which finding would the nurse expect upon auscultating the lung sounds of a patient with heart failure?

crackles in the lung bases

The middle-aged patient reports, "I can't get my breath when I walk." Upon assessment, the nurse notes that the patient has a barrel chest and is using the accessory muscles to breathe. The patient's respiratory rate is 28. On palpation, there is a limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder would the nurse suspect?

emphysema

The nurse is caring for a patient with small amounts of tissue consolidation in the lungs. What will the nurse hear through the stethoscope when the patient whispers a phrase?

the voice is heard like a whisper in the ears.