Physical Assessment Exam 2
Which of the following would be most important for the nurse to remember when auscultating the thorax?
Listen at each site for at least one complete respiratory cycle Explanation: It would be most important to listen at each site for one complete respiratory cycle to obtain the most accurate information.
Which of the following would be most important to assess when a client is noted to be a mouth breather?
Checking for deviated nasal septum Explanation: Inability to breathe through the nose may indicate sinus congestion, obstruction, or a deviated septum.
While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?
Emphysema Explanation: A barrel chest is often seen in emphysema because of hyperinflation of the lungs.
The nurse would suspect a problem at which area when pressure builds up on either side of the tympanic membrane?
Eustachian tube Explanation: The eustachian tube equalizes the pressure on either side of the tympanic membrane, which separates the external ear from the middle ear.
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate. Explanation: Observe quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.
A client with lobar pneumonia would have muffled and indistinct spoken voice sounds. True or False?
False
When percussing the scapula of a client, which sound characteristic would the nurse expect to hear?
Flatness Explanation: Normally, percussion over the scapula elicits flat tones since that is the sound of normal bone. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air, such as in emphysema or pneumothorax.
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
Fluid in the alveoli Explanation: When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds.
Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?
Forward protrusion Explanation: A client with pectus carinatum has a forward protrusion of the sternum causing the adjacent ribs to slope backward. Sunken sternum and adjacent cartilages are seen in funnel chest. Midline and straight position of the sternum is the normal anatomical position. Horizontal sternum with increased intercostal angle is seen in barrel chest.
A nurse in the operating room has a client who just underwent gastric bypass surgery and weighs 243 kilograms (534.6 pounds). Upon extubation, the client's oxygen saturation drops to 84% and the client has difficulty catching her breath. What could be causing these problems?
Obesity, which can limit chest wall expansion and compromise breathing Explanation: Extreme obesity can limit chest wall expansion (and thus compromise breathing).
A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?
Pallor
The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?
Palmar base Explanation: The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation.
On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?
Paralysis of cranial nerve X (vagus) Explanation: Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise.
What color of sputum would support the diagnosis of heart failure?
Pink Explanation: Pink sputum is associated with heart failure. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum?
Pink and frothy Explanation: Pink sputum is associated with pulmonary edema. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with pulmonary edema. Explanation: Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion.
Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?
Knife-like pain that worsens on inspiration Explanation: Knife-like pain that worsens on inspiration is a characteristic finding that indicates pleurisy in the client. Pleurisy or a pleural rub is caused when the inflamed pleural surface comes in contact with each other on inspiration.
The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?
The pattern is expected with this condition Explanation: Pleurisy creates difficulty in getting enough oxygen, and the body responds by increasing the respiratory effort (tachypnea) in an attempt to compensate.
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
The right lung has three lobes, while the left lung has two lobes.
Which of the following findings from the health history of a 70-year-old woman with tinnitus is likely most significant to her diagnosis?
The woman takes aspirin 4 times daily to treat her rheumatoid arthritis. Explanation: Excessive use of aspirin can cause tinnitus.
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
Unequal expansion of the chest Explanation: Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest.
A group of students is reviewing the structures of the ear in preparation for test. The students demonstrate understanding of the material when they identify which structure as part of the middle ear?
Malleus Explanation: The middle ear consists of the ossicles, malleus, incus, and stapes.
A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client?
Maxillary Explanation: If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses, which are located in the upper jaw.
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage Explanation: The auditory characteristics of wheezing result from narrowing of the lumen of a respiratory passage.
The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. How would the nurse document this finding?
Normal expansion Explanation: Normal chest expansion ranges from 5 to 10 cm symmetrically.
While interviewing a client who complains of earache, the nurse asks, "Is there anything that makes it better or worse?" The client replies, "It hurts much worse when I wiggle my ear." Which of the following conditions should the nurse most suspect?
Otitis externa Explanation: Pain caused by "swimmer's ear," or otitis externa, differs from pain felt in middle-ear infections. If you can wiggle the outer ear without pain, the condition is most likely not swimmer's ear.
A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8°F. The mother states that the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition?
Otitis externa Explanation: The key to this condition is that the child was at the beach. Otitis externa occurs as an infection of the external canal from swimming. It presents with a pain and swelling of the ear canal, fever, and purulent drainage.
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Pneumonia Explanation: Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies.
A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?
Pneumothorax Explanation: Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).
Which technique should the nurse use to examine the sinuses of a client with a sinus infection?
Press up on the brow on each side of the nose to palpate the frontal sinus.
While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to
repeat the phrase "ninety-nine." Explanation: To assess bronchophony ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall.
A client appears in the clinic with a cough that began 24 hours prior to coming to this visit. The nurse evaluates the client based on the most common cause of an acute cough, which is
viral respiratory infection
A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:
whispered sounds Explanation: The inability of the client to hear whispered sounds indicates presbycusis, which is a gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve, common in older clients.
A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply.
• Edema • Angina • Orthopnea Explanation: Edema or angina that occurs with dyspnea may indicate a cardiovascular problem. Orthopnea (difficulty breathing when lying supine) may be associated with heart failure.
Which assessment of the tongue should a nurse recognize as abnormal?
Red with loss of papillae Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B 12 or niacin.
Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?
Red, bleeding Explanation: Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia.
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
Resonance Explanation: Normal lung tissue elicits a resonance tone when percussed.
The nurse is assessing the various lobes of the lungs. The nurse must assess which lobe anteriorly?
Right middle lobe Explanation: The right middle lobe of the lung does not extend to the posterior side of the thoracic wall and thus must be assessed form the anterior surface alone.
When assessing a client the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils?
Tonsils are T3
The nurse understands that malocclusion may be related to what?
Tooth loss Explanation: Malocclusion (imperfect positioning of the teeth when the jaw is closed) may occur with tooth loss.
A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?
Torus palatinus Explanation: Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning.
Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?
Vegetable Omelet Explanation: Dietary recommendations for this bleeding disorder include decreasing foods high in salicylates, such as red wine, spices, chocolate, coffee, and some fruits. Provide education about supplements with antiplatelet activity, such as garlic, ginger, ginseng, gingko, and vitamin E. A vegetable omelet would be the most appropriate food choice since it doesn't contain salicylates or antiplatelet supplements.
The nurse is able to identify which vertical reference line of the thorax as a reference line for the posterior thorax?
Vertebral line Explanation: The reference lines for the posterior thorax include the vertebral line, and right and left scapular lines.
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible
chronic bronchitis. Explanation: Labored and noisy breathing is often seen with severe asthma or chronic bronchitis
After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?
hyperresonance Explanation: Generalized hyperresonance may be heard over hyperinflated lungs found in clients with emphysema, a chronic lung disease.
An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible
tuberculosis. Explanation: Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique?
vagal nerve function Explanation: When asking for a client to say "ah" the nurse assesses for the rise of the soft palate and the uvula which is a test of CN X (the vagal nerve) function.
A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope?
• Holding the otoscope so that the thumb is by the window • Holding the client's ear at the helix • Rotating the otoscope slightly Explanation: The examiner should hold the otoscope so that the thumb is by the window and the fingers are bracing the shaft along the client's cheek. The examiner should hold the client's ear at the helix and lift up and back to align the canal for best visualization of the tympanic membrane. After visualization of the canal, the examiner should rotate the otoscope slightly to visualize the entire tympanic membrane, including portions of the malleus, umbo, manubrium, and short process.
When assessing the client's risk for hearing loss, it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.)
• Types of protective equipment used • Instructions for the use of protective ear equipment • Effectiveness of protective equipment Explanation: Clients need to be asked about their exposure to noise and what protective equipment they use. Educating clients on the types, effectiveness, and instructions for the use of protective ear equipment allows them to make decisions based on their needs.
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
"Are you taking any medications on a regular basis?" Explanation: A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension.
A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The client denies exposure to excessive noise levels. What would the nurse ask next?
"What medications are you currently taking?" Explanation: Tinnitus may be associated with certain ototoxic medications.
An adolescent wrestler has been diagnosed with herpes simplex virus with weeping lesions on the face, nose, and lips. The client asks the nurse when he can resume competition wrestling. What is the nurse's best response?
"You can wrestle after the lesions stop weeping and have crusted over." Explanation: Herpes simplex virus is very contagious. Wrestling is a close contact sport, therefore the client should not wrestle until the lesions have stopped weeping and have fully crusted over.
The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as
3+
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
Dullness Explanation: Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.
In which client would the nurse identify receding gums as an expected assessment finding?
A 77-year-old man who describes himself as being healthy Explanation: In older clients, the teeth may appear longer because of age-related gingival recession, which is common.
A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition?
A story his wife is telling him. Explanation: Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds.
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough Explanation: Bronchitis is marked by a chronic, productive cough that results from excess mucus production.
A 68-year-old retired postman presents to the clinic with dull intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and no drug use. He is married with two healthy children. His mother died of breast cancer, and his father died of a stroke. His younger brother has had bypass surgery. Examination finds the client healthy appearing and breathing comfortably. His blood pressure is 140/90, and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds, and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms?
Angina pectoris Explanation: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often radiates to the shoulders, arms, neck, and jaw. It is associated with shortness of breath, nausea, and sweating. The pain is generally relieved by rest or medication after several minutes. This client needs to be admitted to the hospital for further workup for his accelerating symptoms.
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?
Anteroposterior to lateral diameter Explanation: An important component of chest inspection is assessment of the anteroposterior diameter versus the transverse diameter. This is achieved by viewing the client from the back and side.
A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next?
Ask about any medications being used for hypertension. Explanation: The nurse needs to ask the client about medications being used to treat his hypertension. Side effects of certain antihypertensive medications include persistent cough, which is of no consequence except for its annoying nature. Once this information is obtained then the nurse can gather additional information and complete the assessment to ensure that the findings are related to the medication and not another problem
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?
Ask the client if she has recently exerted herself. Explanation: Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral.
The nurse is auscultating a client's breath sounds. What should the nurse do first after hearing an unusual sound?
Ask the client to cough Explanation: If an abnormal sound is heard during auscultation, always have the client cough and then listen again. Coughing may clear the lungs
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?
Bacterial infection Explanation: Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections.
An alternate pathway that bypasses the external and middle ear is called what?
Bone conduction Explanation: An alternate pathway, known as bone conduction, bypasses the external and middle ear and is used for testing purposes.
A client reports a 2-pack-per-day history of cigarette smoking. To assess this client for cancer, which part of the tongue is it most important that the nurse inspect?
Both sides Explanation: The sides of the tongue are the most common area for tongue cancer to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity.
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?
Bradypnea Explanation: A respiratory rate of less than 10 breaths per minute is called bradypnea.
Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.
Bronchial Explanation: These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains 'ee' to & 'aa' changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall.
While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following?
Bronchial breath sounds Explanation: Harsh high pitches sounds short during inspiration and long during expiration reflect bronchial breath sounds, typically heard over the trachea.
When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
Bronchitis Explanation: Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis.
The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?
Cheyne-Stokes Explanation: Cheyne-Stokes respirations, a regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate of less than 10/minute and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
Chronic Obstructive Pulmonary Disease (COPD) Explanation: This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.
Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?
Chronic obstructive pulmonary disease Explanation: An increase in the anterior posterior diameter is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention.
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
Chronic obstructive pulmonary disease Explanation: An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention.
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of what condition?
Chronic obstructive pulmonary disease Explanation: The client is assuming the tripod position, which is often seen in chronic obstructive pulmonary disease.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Coarse crackles Explanation: Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea.
A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. What assessment findings should the nurse anticipate along with this condition?
Crepitus over the maxillary sinuses Explanation: With a sinus infection with large amounts of exudates, the nurse would most likely palpate crepitus over the maxillary sinuses. The frontal or maxillary sinuses would be tender.
The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?
Deviated septum Explanation: The nurse assesses the client's nares for patency when inserting a tube into the nose for feeding. A deviated septum or obstructed nares may make insertion difficult.
Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm Explanation: The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.
The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What would the nurse expect to hear when auscultating the lungs of this client?
Friction rub Explanation: The pleural space is one of the physiologic third spaces for body fluid storage. Severe dehydration will reduce the volume of pleural fluid, resulting in the increased transmission of lung sounds and a possible friction rub.
During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client?
Gingival hyperplasia Explanation: This is gingival hyperplasia, or an overgrowth of gum tissue. It is seen in pregnancy, puberty, leukemia, and medications such as phenytoin.
When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify?
Handle of malleus, short process of malleus, cone of light
Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?
Have the client cough, then listen again Explanation: If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation.
A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?
History of allergies Explanation: Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information.
A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?
Hyperresonance Explanation: Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.
A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?
In the mediastinum Explanation: The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels.
Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client?
Inserting the speculum down and forward into the ear canal
A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. What would the nurse assess first?
Inspect the client's external ear canal. Explanation: Purulent, bloody drainage suggests external otitis, an infection of the external ear canal. Therefore the nurse would need to inspect the external auditory canal.
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Explanation: Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema.
When assessing the apices of the lungs, the nurse would locate them at which position?
Slightly above the clavicle Explanation: The apex of each lung extends slightly above the clavicle.
When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?
Softly repeat the words "one-two-three." Explanation: Softly whispering "one-two-three" while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test.
A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe?
Sound is louder and sounds like "A" Explanation: To perform egophony, the nurse asks the client to repeat the letter "E" while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable.
The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following would the nurse assess next?
Spinal column Explanation: Unequal shoulder and scapula heights in an adolescent may represent scoliosis and may be further assessed by inspecting the spinal column for curves.
A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honor student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?
Spontaneous pneumothorax Explanation: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds; on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan syndrome.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
Stridor Explanation: Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm.
Which of the following is consistent with good percussion technique?
Strike the pleximeter over the distal interphalangeal joint. Explanation: Percussion takes practice to master. Most struggle initially with keeping the wrist and hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off the chest wall. These can dampen the sound that the examiner is trying to obtain. The ideal target for the plexor is the distal interphalangeal joint.
The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis?
Sudden onset of dyspnea Explanation: The arterial occlusion that results in pulmonary embolism normally manifests as a sudden onset of dyspnea, which deep breathing is unlikely to relieve, because part of the pulmonary arterial tree is occluded.
When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi?
T4 spinous process Explanation: The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.
A person with a barrel chest has a problem doing what?
Taking a deep breath Explanation: Auscultation of all lung fields may not be possible because deep breathing generally worsens the level of fatigue in clients with pulmonary disorders.
A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?
The client has unilateral hearing loss Explanation: The Weber test helps to differentiate the cause of unilateral hearing loss.
The nurse's assessment of an 81-year-old client's hearing has corroborated her recent history of hearing loss. The nurse questions the client about her use of hearing aids, to which the client responds, "I've got enough frustration in my life without having to fiddle with those." The nurse should suspect which of the following?
The client may have had a negative experience with hearing aids in the past. Explanation: The older client may have had a bad experience with certain hearing aids and may refuse to wear one. The client may also associate a negative self-image with a hearing aid.
Which of the following on thoracic inspection of adult clients would the nurse consider an expected finding?
The client's lateral diameter is larger than the anteroposterior diameter. Explanation: The chest of a healthy adult is wider than it is deep.
Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?
There is loss of involuntary respiratory control. Explanation: The brainstem contains the medulla and the pons, which control involuntary respiratory effort.
The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the
area underneath the tongue.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
ask the client to breathe deeply through her mouth. Explanation: To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation.
As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test the nurse should place the base of the tuning fork:
at the center of the client's forehead
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?
less than 90 degrees Explanation: The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema.
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium. Explanation: The clavicles extend from the manubrium to the acromion of the scapula.
Which pleural membrane lines the chest cavity?
parietal pleura Explanation: The thin, double-layered serous membrane that lines the thoracic cavity is called the pleura. The parietal pleura is the layer which lines the chest cavity, and the visceral pleura covers the exterior of the lungs.
While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible
pneumonia. Explanation: Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia.
