EXAM 3 EVERYTHING: CH 18: Thorax and Lungs, Chapter 19: Heart and Neck Vessels, Chapter 20: Peripheral Vascular System and Lymphatic System, Chapter 21: Abdomen, 352 EXAM 3

The nurse knows that during an abdominal assessment, deep palpation is used to determine: 1. bowel motility. 2. enlarged organs. 3. superficial tenderness. 4. overall impression of skin surface and superficial musculature.

ANS: 2 With deep palpation, note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

The nurse notes that a patient has had a black, tarry stool and recalls that a possible cause would be: 1. gallbladder disease. 2. overuse of laxatives. 3. gastrointestinal bleeding. 4. localized bleeding around the anus.

ANS: 3 Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus.

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: 1. aphasia. 2. dysphasia. 3. dysphagia. 4. myophagia.

ANS: 3 Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing.

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." b. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." c. "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." d. "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate."

ANS: "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

A nurse notes that a patient has ascites, which indicates that which of the following is present? 1. Fluid 2. Feces 3. Flatus 4. Fibroid tumors

ANS: 1 Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Just before going home, a new mother asks the nurse about the umbilical cord. The nurse would tell her: 1. it should fall off by 10 to 14 days. 2. at birth the cord is a bluish color. 3. it contains two veins and one artery. 4. skin will cover the area within 1 week.

ANS: 1 At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton's jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin will cover the area by 3 to 4 weeks.

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? 1. This is the result of peripheral vasodilatation and is an expected change. 2. Because of increased cardiac output, the blood pressure should be higher this time. 3. This is not an expected finding because it would mean a decreased cardiac output. 4. This would mean a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: 1 Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: 1. projectile vomiting. 2. hypoactive bowel activity. 3. palpable olive-sized mass in right lower quadrant. 4. pronounced peristaltic waves crossing from right to left.

ANS: 1 Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

In percussing the left cardiac border, the nurse would expect to hear dullness at the 1. third left intercostal space midclavicular line and fifth left intercostal space left sternal border. 2. fourth left intercostal space medial to midclavicular line and second left intercostal space midclavicular line. 3. fifth left intercostal space midclavicular line and second left intercostal space sternal border. 4. fifth left intercostal space sternal border and second right intercostal space midclavicular line.

ANS: 1 Normally, the left border of cardiac dullness is at the midclavicular line in the fifth interspace and slopes in toward the sternum as you progress upward so that by the second interspace the border of dullness coincides with the left sternal border.

In performing auscultation of heart sounds, which sequence would the nurse use 1. Aortic area—pulmonic area—Erb's point—tricuspid area—mitral area 2. Pulmonic area—aortic area—Erb's point—tricuspid area—mitral area 3. Aortic area—tricuspid area—Erb's point—mitral area—pulmonic area 4. Pulmonic area—Erb's point—tricuspid area—pulmonic area—mitral area

ANS: 1 Sounds produced by the valves may be heard all over the precordium. Therefore, learn to inch your stethoscope in a Z pattern, from the base of the heart across and down, and then over to the apex. Or start at the apex and work your way up.

The mother of a 10-month-old tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? 1. Tetralogy of Fallot 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect

ANS: 1 Tetralogy of Fallot subjective findings include (1) severe cyanosis, not in the first months of life but developing as the infant grows, and right ventricle outflow (i.e., pulmonic) stenosis gets worse; (2) cyanosis with crying and exertion at first, then at rest; (3) slowed development. Objective findings include (1) thrill palpable at left lower sternal border; (2) S1 normal, S2 has A2 loud and P2 diminished or absent; (3) murmur is systolic, loud, crescendo-decrescendo.

Which sound is normal to elicit when percussing in the seventh right intercostal space at the midclavicular line over the liver? 1. Dullness 2. Tympany 3. Resonance 4. Hyperresonance

ANS: 1 The liver is located in the right upper quadrant and would elicit a dull percussion note.

The sac that surrounds and protects the heart is called the: 1. pericardium. 2. myocardium. 3. endocardium. 4. pleural space.

ANS: 1 The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid.

During an assessment of a 68-year-old man with a recent onset of right- sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: 1. a valvular disorder. 2. blood flow turbulence. 3. fluid volume overload. 4. ventricular hypertrophy.

ANS: 2 A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present

The vital signs of a 70-year-old patient with a history of hypertension are BP 180/100 and HR 90. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while patient is in left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely: 1. split S1. 2. atrial gallop. 3. diastolic murmur. 4. summation sound.

ANS: 2 A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex with the patient in the left lateral position.

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: 1. 1 minute. 2. 5 minutes. 3. 10 minutes. 4. 2 minutes in each quadrant.

ANS: 2 Absent bowel sounds are rare. The nurse must listen for 5 minutes by the watch before deciding bowel sounds are completely absent.

The nurse is listening to bowel sounds. Which of the following is true of bowel sounds? 1. They are usually loud, high-pitched, rushing, tinkling sounds. 2. They are usually high-pitched, gurgling, irregular sounds. 3. They sound like "two pieces of leather being rubbed together." 4. They originate from the movement of air and fluid through the large intestine.

ANS: 2 Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: 1. diarrhea. 2. peritonitis. 3. laxative use. 4. gastroenteritis.

ANS: 2 Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

In assessing a 70-year-old man, the nurse finds the following: BP 140/100 mm Hg; HR 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? 1. Increase in resting heart rate 2. Increase in systolic blood pressure 3. Decrease in diastolic blood pressure 4. Increase in diastolic blood pressure

ANS: 2 From ages 20 to 80 years, systolic blood pressure tends to increase within the normal range by 25% to 30%. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging.

A patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: 1. increased gastric acid secretion. 2. decreased gastric acid secretion. 3. delayed gastrointestinal emptying time. 4. increased gastrointestinal emptying time.

ANS: 2 Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: 1. palpate the artery in the upper one third of the neck. 2. listen with the bell of the stethoscope to assess for bruits. 3. palpate both arteries simultaneously to compare amplitude. 4. instruct patient to take slow deep breaths during auscultation.

ANS: 2 If cardiovascular disease is suspected, auscultate each carotid artery for the presence of a bruit. Avoid compressing the artery because this could create an artificial bruit and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis.

Which of the following statements regarding the aging adult and abdominal assessment is true? 1. The abdominal tone is increased. 2. The abdominal musculature is thinner. 3. The abdominal rigidity with acute abdominal conditions is more common. 4. The aging person complains of more pain with an acute abdomen than a younger person would.

ANS: 2 In the aging person, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with acute abdominal conditions is less common in aging. The aging person often complains less of pain than a younger person would with an acute abdomen.

28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse will conduct which of the following to assess for this condition? 1. Obturator test 2. Murphy's sign 3. Assess for rebound tenderness 4. Iliopsoas muscle test

ANS: 2 Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration. The person feels sharp pain and abruptly stops inspiration midway.

While auscultating heart sounds on a 7-year-old for a "routine physical," the nurse hears the following: an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of the following would be true regarding the findings? 1. S3 is indicative of heart disease in children. 2. These can all be normal findings in a child. 3. These are indicative of congenital problems. 4. The venous hum most likely indicates an aneurysm.

ANS: 2 Physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.

The nurse is assessing the abdomen of a pregnant woman, who is complaining of having a "stomach ache" all the time. The nurse knows that esophageal reflux during pregnancy can cause: 1. diarrhea. 2. pyrosis. 3. dysphagia. 4. constipation.

ANS: 2 Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy.

The direction of blood flow through the heart is best described by which of the following? 1. Vena cava—right atrium—right ventricle—lungs—pulmonary artery—left atrium —left ventricle 2. Right atrium—right ventricle—pulmonary artery—lungs—pulmonary vein—left atrium—left ventricle 3. Aorta—right atrium—right ventricle—lungs—pulmonary vein—left atrium—left ventricle—vena cava 4. Right atrium—right ventricle—pulmonary vein—lungs—pulmonary artery—left atrium—left ventricle

ANS: 2 Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta.

The component of the conduction system referred to as the pacemaker of the heart is the: 1. atrioventricular (AV) node. 2. sinoatrial (SA) node. 3. bundle of His. 4. bundle branches.

ANS: 2 Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. (Because the SA node has an intrinsic rhythm, it is the "pacemaker.")

In assessing for an S4 with a stethoscope, the nurse would listen with the: 1. bell at the base with the patient leaning forward. 2. bell at the apex with the patient in the left lateral position. 3. diaphragm in the aortic area with the patient sitting. 4. diaphragm in the pulmonic area with the patient supine.

ANS: 2 The S4 is a ventricular filling sound. It occurs when atria contract late in diastole. It is heard immediately before S1. This is a very soft sound, of very low pitch. You need a good bell, and you must listen for it. It is heard best at the apex, with the person in the left lateral position.

The main reason auscultation precedes percussion and palpation of the abdomen is to: 1. determine areas of tenderness before using percussion and palpation. 2. prevent distortion of bowel sounds that might occur after percussion and palpation. 3. allow the patient more time to relax and therefore be more comfortable with the physical examination. 4. prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.

ANS: 2 This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Which of the following is a normal finding in the abdominal assessment? 1. The presence of a bruit in the femoral area 2. A tympanic percussion note in the umbilical region 3. A palpable spleen between the ninth and eleventh ribs in the left midaxillary line 4. A dull percussion note in the left upper quadrant at the midclavicular line

ANS: 2 Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (option 4).

Which of the following describes the closure of the valves in a normal cardiac cycle? 1. The aortic valve closes slightly before the tricuspid valve. 2. The pulmonic valve closes slightly before the aortic valve. 3. The tricuspid valve closes slightly later than the mitral valve. 4. Both the tricuspid and pulmonic valves close at the same time.

ANS: 3 Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes you can hear them separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

When assessing a newborn infant who is just 5 minutes old, the nurse knows that which of the following would be true? 1. The left ventricle is larger and weighs more than the right. 2. The circulation of a newborn is identical to that of an adult. 3. There is an opening in the atrial septum where blood can flow into the left side of the heart. 4. The foramen ovale closes just minutes before birth and the ductus arteriosus closes immediately after.

ANS: 3 First, about two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour because the pressure in the right side of the heart is now lower than in the left side.

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? 1. Family history, hypertension, stress, age 2. Personality type, high cholesterol, diabetes, smoking 3. Smoking, hypertension, obesity, diabetes, high cholesterol 4. Alcohol consumption, obesity, diabetes, stress, high cholesterol

ANS: 3 For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dl or known diabetes mellitus, obesity, cigarette smoking, low activity level.

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but with the patient sitting and leaning forward, the nurse hears a high-pitched, scratchy sound at the apex with the diaphragm. It disappears on inspiration. The nurse suspects: 1. increased cardiac output. 2. another myocardial infarction. 3. inflammation of the precordium. 4. ventricular hypertrophy resulting from muscle damage.

ANS: 3 Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed: It is best heard with the diaphragm, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, places where the pericardium comes in close contact with the chest wall.

Which of the following statements is true regarding an aortic aneurysm? 1. A bruit is absent. 2. Femoral pulses are increased. 3. A pulsating mass is usually present. 4. Most are located below the umbilicus.

ANS: 3 Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: 1. pulsations of the renal arteries. 2. pulsations of the inferior vena cava. 3. normal abdominal aortic pulsations. 4. increased peristalsis from a bowel obstruction.

ANS: 3 Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.

26. During the precordial assessment on an 8-month pregnant patient, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This would indicate 1. right ventricular hypertrophy. 2. increased volume and size of the heart as a result of pregnancy. 3. displacement of the heart from elevation of the diaphragm. 4. increased blood flow through the internal mammary artery.

ANS: 3 Palpation of the apical impulse is higher and lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

A 45-year-old man is in the clinic for "a routine physical." During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: 1. "When was your last electrocardiogram?" 2. "It's probably because it's been so hot at night." 3. "Do you have any history of problems with your heart?" 4. "Have you had a recent sinus infection or upper respiratory infection?"

ANS: 3 Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

Percussion notes heard during the abdominal assessment may include: 1. flatness, resonance, and dullness. 2. resonance, dullness, and tympany. 3. tympany, hyperresonance, and dullness. 4. resonance, hyperresonance, and flatness.

ANS: 3 Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be palpated over a distended bladder or enlarged spleen or liver.

When listening to heart sounds, the nurse knows that which of the following statements concerning S1 is true? 1. S1 is louder than S2 at the base. 2. S1 indicates the beginning of diastole. 3. S1 coincides with the carotid artery pulse. 4. S1 is caused by closure of the semilunar valves.

ANS: 3 S1 is the start of systole, and is louder than S2 at the apex; S2 is louder than S1 at the base. S1 coincides with carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1.

To detect diastasis recti, the nurse should have the patient perform which of the following maneuvers? 1. Relax in the supine position. 2. Raise arms in the left lateral position. 3. Raise arms over the head while supine. 4. Raise the head while remaining supine.

ANS: 4 Diastasis recti is a separation of the abdominal rectus muscles, which can congenitally, as a result of pregnancy, or from marked obesity. This is assessed by having the patient raise the head while remaining supine.

Which of the following would the nurse expect to find during a cardiac assessment on a 4-year-old child? 1. S3 when sitting up 2. Persistent tachycardia above 150 3. Murmur at second left intercostal space when supine 4. Palpable apical impulse in fifth left intercostal space lateral to midclavicular line

ANS: 3 Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The contractile force of the heart is greater in children. This increases blood flow velocity. The increased velocity plus a smaller chest measure- ment makes an audible murmur. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

The electrical stimulus of the cardiac cycle follows which sequence? 1. AV node—SA node—bundle of His 2. Bundle of His—AV node—SA node 3. SA node—AV node—bundle of His—bundle branches 4. AV node—SA node—bundle of His—bundle branches

ANS: 3 Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

A patient is complaining of tenderness along the costovertebral angles. The nurse knows that this symptom is most often indicative of: 1. ovary infection. 2. liver enlargement. 3. kidney inflammation. 4. spleen enlargement.

ANS: 3 Tenderness along the costovertebral angles occurs with inflammation of the kidney or paranephric area.

Tenderness on light palpation in the right lower quadrant could indicate a disorder of which of the following structures? 1. Spleen 2. Sigmoid 3. Appendix 4. Gallbladder

ANS: 3 The appendix is located in the right lower quadrant and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant.

While counting the apical pulse on a 16-year-old patient, the nurse notes an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? 1. Talk with the patient about his intake of caffeine. 2. Do an electrocardiogram after the exam. 3. No further response is needed because this is normal. 4. Refer the patient to a cardiologist for further testing.

ANS: 3 The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration, and slowing with expiration.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: 1. mitral, tricuspid. 2. tricuspid, aortic. 3. aortic, pulmonic. 4. mitral, pulmonic.

ANS: 3 The second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base.

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the fourth-fifth left intercostal space at the midclavicular line. This finding most likely suggests: 1. a normal heart. 2. a systolic murmur. 3. enlargement of the left ventricle. 4. enlargement of the right ventricle.

ANS: 4 A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex.

A patient's abdomen is bulging and stretched in appearance. The nurse would describe this finding as: 1. obese. 2. herniated. 3. scaphoid. 4. protuberant.

ANS: 4 A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7.

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what would the nurse do? 1. Have patient turn to the left side and listen with the bell. 2. Ask patient to hold his breath while the nurse listens again. 3. No further assessment is needed because the nurse knows it is an S3. 4. Watch patient's respirations while listening for effect on the sound.

ANS: 4 A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When you first hear the split S2, do not be tempted to ask the person to hold his or her breath so that you can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, concentrate on the split as you watch the person's chest rise up and down with breathing.

The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is: 1. increased salivation. 2. decreased peristalsis. 3. increased esophageal emptying. 4. decreased gastric acid secretion.

ANS: 4 As one ages, salivation decreases, esophageal emptying is delayed, and peristalsis is thought to remain fairly constant. Gastric acid secretion decreases with aging. Decreased peristalsis may result from decreased bulk in diet, decreased fluid intake, or laxative abuse.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: 1. decreased fluid volume. 2. increased cardiac output. 3. narrowing of jugular veins. 4. increased pressure in the right side of his heart.

ANS: 4 Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with right-sided heart failure.

The physician comments that a patient has abdominal "borborygmi." The nurse knows that this term refers to: 1. a loud continuous hum. 2. a peritoneal friction rub. 3. hypoactive bowel sounds. 4. hyperactive bowel sounds.

ANS: 4 Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.

To the horizontal plane, a scaphoid contour of the abdomen depicts: 1. a flat profile. 2. a convex profile. 3. a bulging profile. 4. a concave profile.

ANS: 4 Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane.

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? 1. Percuss and palpate in the lumbar region. 2. Inspect and palpate in the epigastric region. 3. Auscultate and percuss in the inguinal region. 4. Percuss and palpate in the hypogastric region.

ANS: 4 Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of the following is true regarding assessment of the spleen in this situation? 1. The spleen can be enlarged as a result of trauma. 2. The spleen is normally felt upon routine palpation. 3. If an enlarged spleen is noted, palpate thoroughly to determine size. 4. An enlarged spleen should not be palpated because it can rupture easily.

ANS: 4 If you feel an enlarged spleen, refer the person but do not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? 1. Third left intercostal space at the midclavicular line 2. Fourth left intercostal space at the sternal border 3. Fourth left intercostal space at the anterior axillary line 4. Fifth left intercostal space at the midclavicular line

ANS: 4 Location—the apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular line.

Which structure is located in the left lower quadrant of the abdomen? 1. Liver 2. Duodenum 3. Gallbladder 4. Sigmoid colon

ANS: 4 The sigmoid colon is located in the left lower quadrant of the abdomen.

The mother of a 3-month-old states that her daughter has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? 1. The position that baby sleeps in 2. Sibling history of eating disorders 3. Amount of background noise when eating 4. Presence of dyspnea or diaphoresis when sucking

ANS: 4 To screen for heart disease in an infant, focus on feeding. Note fatigue during feeding. Infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic and then falls into exhausted sleep and awakens after a short time hungry again.

Which of the following best describes what is meant by atrial kick? 1. The atria contract during systole and attempt to push against closed valves. 2. The contraction of the atria at the beginning of diastole can be felt as a palpitation. 3. This is the pressure exerted against the atria as the ventricles contract during systole. 4. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: 4 Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick."

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. b. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. e. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.

ANS: A. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. C. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse diameter ratio of 1:1

ANS: An anteroposterior-to-transverse diameter ratio of 1:1 An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? a. Obtaining a detailed health history of the patient's allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

ANS: Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side

ANS: Between the scapulae Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion

ANS: Chest pain that is worse on deep inspiration, dyspnea Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing

ANS: Friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with several diseases, such as pneumonia, heart failure, chronic bronchitis, and others (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort

ANS: When part of the lung is obstructed or collapsed Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing

ANS: Hypoventilation Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? a. Listening to at least one full respiration in each location b. Listening as the patient inhales and then going to the next site during exhalation c. Instructing the patient to breathe in and out rapidly while listening to the breath sounds d. If the patient is modest, listening to sounds over his or her clothing or hospital gown

ANS: Listen to at least one full respiration in each location. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Adventitious sounds and limited chest expansion. b. Increased tactile fremitus and dull percussion tones. c. Muffled voice sounds and symmetric tactile fremitus. d. Absent voice sounds and hyperresonant percussion tones.

ANS: Muffled voice sounds and symmetric tactile fremits. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Airway obstruction b. Emphysema c. Pulmonary consolidation d. Asthma

ANS: Pulmonary consolidation Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? a. Croup b. Tuberculosis c. Viral infection d. Pulmonary edema

ANS: Pulmonary edema Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema (or it may be a side effect of sympathomimetic medications). Croup is associated with a "barking" cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds

ANS: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea are seen with tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia. See Table 18-8.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult? a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. c. Decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

ANS: The lungs are less elastic and distensible, which decreases their ability to collapse and recoil. In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Crepitus palpated at the costochondral junctions b. No diaphragmatic excursion as a result of a child's decreased inspiratory volume c. Presence of bronchovesicular breath sounds in the peripheral lung fields d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

ANS: The presence of bronchovesicular breath sounds in the peripheral lung fields Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults, so breath sounds are louder and harsher.

When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

ANS: The shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the chest d. Lightly holding the bell of the stethoscope against the chest to avoid friction

ANS: Use the diaphragm of the stethoscope held firmly against the chest. The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchial sounds c. Bronchophony d. Whispered pectoriloquy

ANS: Wheezes Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. a. Side-to-side b. Top-to-bottom c. Posterior-to-anterior d. Interspace-by-interspace

ANS: side-to-side Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are incorrect.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When the bronchial tree is obstructed b. When adventitious sounds are present c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia

ANS: When the bronchial tree is obstructed Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.

ANS: a normal finding in a healthy adult. The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: a. Bronchitis. b. Pneumothorax. c. Acute pneumonia. d. Asthmatic attack.

ANS: a pneumothorax. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. See Table 18-8 for descriptions of the other conditions.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: a. Asthma. b. Atelectasis. c. Lobar pneumonia. d. Heart failure.

ANS: asthma. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes.

ANS: atelectatic crackles, and that they are not pathologic. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

When assessing a patient's lungs, the nurse recalls that the left lung: a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

ANS: consists of two lobes. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: a. Tactile fremitus. b. Crepitus. c. Friction rub. d. Adventitious sounds.

ANS: crepitus. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: a. Increased thoracic expansion. b. Decreased mobility of the thorax. c. Decreased anteroposterior diameter. d. Bronchovesicular breath sounds throughout the lungs.

ANS: decreased mobility of the thorax. The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

The primary muscles of respiration include the: a. Diaphragm and intercostals. b. Sternomastoids and scaleni. c. Trapezii and rectus abdominis. d. External obliques and pectoralis major.

ANS: diaphragm and intercostals. The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles (sternomastoids, scalene, trapezii). Forced expiration involves the abdominal muscles.

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a. Dullness. b. Tympany. c. Resonance. d. Hyperresonance.

ANS: dullness. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are: a. Musical in quality. b. Usually caused by a pathologic disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration.

ANS: expected near the major airways. Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

ANS: extend 3 to 4 cm above the inner third of the clavicles. The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: a. Shallow breathing. b. Normal lung tissue. c. Decreased adipose tissue. d. Increased density of lung tissue.

ANS: increased density of lung tissue. A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile remits: a. "Is caused by moisture in the alveoli." b. "Indicates that air is present in the subcutaneous tissues." c. "Is caused by sounds generated from the larynx." d. "Reflects the blood flow through the pulmonary arteries."

ANS: is caused by sounds generated from the larynx." Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate: a. Pneumonia. b. Postnasal drip or sinusitis. c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking.

ANS: postnasal drip or sinusitis. A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: a. Assure the mother that these signs are normal symptoms of a cold. b. Recognize that these are serious signs, and contact the physician. c. Ask the mother if the infant has had trouble with feedings. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

ANS: recognize that these are serious signs and contact the physician. The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and assessment of the infant's feeding is not a priority at this time.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: a. Costal angle. b. Sternal angle. c. Xiphoid process. d. Suprasternal notch.

ANS: sternal angle. The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

The nurse knows that auscultation of fine crackles would most likely be noticed in: a. A healthy 5-year-old child. b. A pregnant woman. c. The immediate newborn period. d. Association with a pneumothorax.

ANS: the immediate newborn period. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: a. The spinous process of C7. b. Usually nonpalpable in most individuals. c. Opposite the interior border of the scapula. d. Located next to the manubrium of the sternum.

ANS: the spinous process of C7. The spinous process of C7 is the vertebra prominens. It is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: a. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema.

ANS: tuberculosis. Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. See Table 18-8.

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: a. Normally auscultated over the trachea. b. Bronchial breath sounds and normal in that location. c. Vesicular breath sounds and normal in that location. d. Bronchovesicular breath sounds and normal in that location.

ANS: vesicular breath sounds and are normal in that location. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.