Chapter 17: Pulmonary Clinical Assessment

How does the patient history assist the nurse in developing the management plan? (Select all that apply.) a. Provides direction for the rest of the assessment b. Exposes key clinical manifestations. c. Aids in developing the plan of care d. The degree of the patient's distress determines the extent of the interview. e. Determines length of stay in the hospital setting.

Answer: A, B, C, D Rationale: The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.

What is the sequence for auscultation of the anterior chest? a. Right side, top to bottom, then left side, top to bottom. b. Left side, top to bottom, then right side, top to bottom. c. Side to side, bottom to top. d. Side to side, top to bottom.

Answer: d. Side to side, top to bottom. Rationale: Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.

Which conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment? (Select all that apply.) a. Normal lung. b. Bronchiectasis. c. Emphysema. d. Acute bronchitis. e. Diffuse pulmonary fibrosis.

Answer: A, B, D Rationale: The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration greater than expiration ratio. Acute bronchitis can also have inspiration that equals expiration ratio as also seen with emphysema, diffuse pulmonary fibrosis, and consolidating pneumonia. Noting that many conditions present with the same findings affirms the need for further assessment and evaluation.

Deviation of the trachea occurs in which conditions? (Select all that apply.) a. Pneumothorax. b. Pulmonary fibrosis. c. Chronic obstructive pulmonary disease. d. Emphysema e. Pleural effusion

Answer: A, B, E Rationale: Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding? a. A shift to the right. b. A shift to the left. c. No deviation d. Subcutaneous emphysema.

Answer: a. A shift to the right. Rationale: With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what condition? a. Hypoxia b. Dyspnea c. Dehydration d. Malnutrition

Answer: a. Hypoxia Rationale: Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection, this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which finding is unexpected? a. Increased diaphragmatic excursion. b. Decreased tactile fremitus. c. Dull percussion tones. d. Pleural friction rub.

Answer: a. Increased diaphragmatic excursion. Rationale: Assessment findings associated with pleural effusion include dullness on percussion, decreased tactile fremitus, pleural friction rub, and decreased diaphragmatic excursion. Increased diaphragmatic excursion is not associated with acute bronchitis.

When assessing a patient, the use of observation is referred to as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: a. Inspection Rationale: Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

In what condition are bronchophony, egophony, and whispering pectoriloquy increased? a. Pneumonia with consolidation b. Pneumothorax c. Asthma d. Bronchiectasis

Answer: a. Pneumonia with consolidation Rationale: Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an "a" sound when the patient is saying "e."

A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis

Answer: a. Tension pneumothorax Rationale: Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are indicative of tension pneumothorax.

The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding is unexpected? a. Rasping productive cough. b. Decreased tactile fremitus. c. Resonant percussion tones. d. Crackles and wheezes.

Answer: b. Decreased tactile fremitus. Rationale: Assessment findings associated with acute bronchitis include rasping productive cough, resonance on percussion, crackles and wheezes, and normal to increased tactile fremitus. Decreased tactile fremitus is not associated with acute bronchitis.

A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness

Answer: b. Hyperresonance Rationale: The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.

When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: b. Palpation Rationale: Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the patient's breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation. b. Tachypnea. c. Obstructive breathing. d. Bradypnea.

Answer: b. Tachypnea. Rationale: Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

While palpating a patient's lungs the nurse notes fremitus over the patient's trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion. b. Bronchial obstruction. c. A normal finding. d. Apical pneumothorax.

Answer: c. A normal finding. Rationale: Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient's tongue is blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find? a. Kussmaul breathing pattern. b. Absent breath sounds in the right lower lung fields. c. Absent breath sounds in the left lung fields. d. Diminished breath sounds in the right upper lung fields.

Answer: c. Absent breath sounds in the left lung fields. Rationale: The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.

A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. d. Complete the history and then provide measures to assist the patient to breathe easier.

Answer: c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. Rationale: The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and the precipitating events.

The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis. Which finding is unexpected? a. Diminished thoracic expansion. b. Tracheal deviation to the most affected side. c. Hyperresonant percussion tones. d. Decreased breath sounds.

Answer: c. Hyperresonant percussion tones. Rationale: Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion, tracheal deviation to the most affected side, decreased or absent breath sounds, and resonance or dullness on percussion. Hyperresonance is not an expected finding in pulmonary fibrosis.

A patient is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurses notes that the patient has difficulty getting breath out. Which phrase best describes the patient's breathing pattern? a. Deep sighing breaths without pauses. b. Rapid, shallow breaths. c. Normal breathing pattern interspersed with forced expirations. d. Irregular breathing pattern with both deep and shallow breaths.

Answer: c. Normal breathing pattern interspersed with forced expirations. Rationale: Difficulty getting breath out is indicative of air trapping. Air trapping is described as a normal breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until the patient actively and forcefully exhales.

What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: c. Percussion Rationale: Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

A patient is admitted with acute lung failure secondary to chronic obstructive pulmonary disease (COPD). Upon inspection of the patient, the nurse observes that the patient's fingers appear discolored. What does this finding indicate the presence of? a. Clubbing. b. Central cyanosis. c. Peripheral cyanosis d. Chronic tuberculosis.

Answer: c. Peripheral cyanosis Rationale: Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life-threatening situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of oxygen often related to a heart or lung disease.

The nurse is observing a new graduate listen to a patient's lungs. Which action by the new graduate indicates a need to review auscultation skills? a. The nurse starts at the apices and moves to the bases. b. The nurse compares breath sounds from side to side. c. The nurse listens during inspiration. d. The nurse listens posteriorly, laterally, and anteriorly.

Answer: c. The nurse listens during inspiration. Rationale: Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly.

What assessment technique involves having the patient breathe in and out slowly with an open mouth? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: d. Auscultation Rationale: Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

Which lung sounds would be most likely heard in a patient experiencing an asthma attack? a. Coarse rales. b. Pleural friction rub. c. Fine crackles. d. Expiratory wheezes.

Answer: d. Expiratory wheezes. Rationale: Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema. b. Atelectasis. c. Pulmonary fibrosis. d. Pleural effusion.

Answer: d. Pleural effusion. Rationale: A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.

Which condition is an example of a disorder with increased tactile fremitus? a. Emphysema b. Pleural effusion c. Pneumothorax d. Pneumonia

Answer: d. Pneumonia Rationale: Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus.