MyNursingLabs 8.1 and 8.2 Lungs and Thorax Physical Assessment & Abnormalities
The nurse is assessing the thoracic cavity of a child. Which statement demonstrates that the nurse understands the anatomy of the chest? "The thoracic cavity of a child can only be auscultated from the front." "I will palpate the ribs anteriorly." "I will inspect, auscultate, and palpate the thoracic cavity from the base of the neck to the diaphragm." "The posterior ribs are the best place to assess the thoracic cavity of a child."
"I will inspect, auscultate, and palpate the thoracic cavity from the base of the neck to the diaphragm." The thoracic cavity of a child or an adult is assessed from the base of the neck down to the diaphragm, both front and back, by percussion, inspection, and auscultation. The size of the child does not change the description of the anatomy of the thoracic cavity.
The nurse is assessing a child with a history of asthma. What symptoms would the child with an acute asthma episode likely exhibit? Select all that apply. Anxiety Hacking cough Systemic allergic rash Wheezing Clear and regular lung sounds in all fields on auscultation
Anxiety Hacking cough Wheezing A child with asthma can have wheezing, cough, decreased respiratory effort, decreased lung sounds, and anxiety. Typically, a child having an acute asthma episode will not have a systemic allergic rash. A child would not have clear lung sounds during an asthma attack but may have little to no air movement during inspiration and exhalation. Asthma is often misdiagnosed because children with asthma may have only a cough that does not let them catch their breath during an episode.
The nurse is performing a focused assessment of the respiratory system on an adult client in no distress. What would be the normal configurations of the chest for this client? Substernal retractions on inspiration Chest is symmetrical, and the chest wall rises and falls equally during respiration Intercostal retractions during respiration Asymmetrical chest wall
Chest is symmetrical, and the chest wall rises and falls equally during respiration The nurse would inspect the appearance of the thorax or chest wall during a focused physical exam. The chest wall would be symmetrical and equal on both sides of the chest. The rise and fall of the chest during respiration would be equal. There would be no evidence of substernal or intercostal retractions in a healthy adult client not in respiratory distress. The adult male may use more abdominal muscles when breathing, but doing so would not cause retractions.
The nurse is assessing a young adult with chronic bronchitis. What symptoms would the nurse expect to assess to confirm this diagnosis? Select all that apply. Chronic productive cough Hyperresonance upon percussion Dyspnea Use of accessory muscles when breathing Wheezes and rhonchi are present on auscultation of the lungs
Chronic productive cough Dyspnea Use of accessory muscles when breathing Wheezes and rhonchi are present on auscultation of the lungs Clients with chronic bronchitis have airway inflammation and swelling, which leads to difficulty breathing and a rapid respiratory rate. Often a chronic productive cough persists, and the client begins using accessory muscles to help with breathing. Wheezes and rhonchi may be present. The nurse should percuss resonance, not hyperresonance, when a client has chronic bronchitis.
Crackles/rales occur at the end of inspiration and are caused by what? Blocked airflow Pleural inflammation Collapsed or fluid-filled alveoli Obstructed upper airway
Collapsed or fluid-filled alveoli Crackles/rales occur at the end of inspiration and can be high-pitched, short, and crackling, or loud, moist, low-pitched, and bubbling. Crackles/rales are caused by collapsed or fluid-filled alveoli. An obstructed upper airway would be indicated by stridor, a type of rhonchi that is continuous. Pleural inflammation is indicated by friction rub, and blocked airflow is indicated by wheezes.
The nurse is assessing a 5-month-old infant in the emergency department. The infant is irritable and is making a loud, high-pitched crowing noise with every respiration. What abnormal respiratory condition might this infant be experiencing? Croup Asthma Bronchitis COPD
Croup Infants who make a loud, high-pitched crowing sound that sounds like it is in the neck and upper airway are likely to be experiencing croup. Chronic obstructive pulmonary disease (COPD) is diagnosed in adults and is a disease of the alveoli. Asthma is an inflammation of the airway but is associated with wheezing and cough. Bronchiolitis and bronchitis are associated with congestion and cough lower in the chest, and infants with either disease would not make a high-pitched, crowing sound when breathing.
The nurse is assessing an adult client for respiratory mechanical movement and understands that many factors would be considered. What factor would the nurse expect to cause an increase in mechanical movement? Guarding related to pain Muscle atrophy Compromised nerve supply Decrease in fatty tissue and weight loss
Decrease in fatty tissue and weight loss A decrease in fatty tissue, as in a lean body frame, would increase the mechanical movement rather than decrease it.Compromised nerve supply, muscle atrophy and guarding relating to pain would result in decreased mechanical movement. The nurse would note shallow breaths, poor chest excursion during the assessment.
The nurse is inspecting the chest of an adult client. Which observations of the respiratory cycle are considered abnormal findings for a healthy adult? Select all that apply. Dusky or blue lips Substernal retractions during a respiratory cycle Pink or pale skin tones Respiratory rate of 52 breaths/min at rest Asymmetry of the chest wall
Dusky or blue lips Substernal retractions during a respiratory cycle Respiratory rate of 52 breaths/min at rest Asymmetry of the chest wall The normal respiratory cycle of an adult is at a rate between 12 and 20 breaths/min. The skin is pale, pink, or pale with pink undertones. There is no evidence of retractions, and the chest appears symmetrical. Asymmetry is considered abnormal, as is a respiratory rate of greater than 40 breaths/min, dusky lips, and substernal retractions.
Bobby Castro is a 6-year-old who was brought to the emergency department with respiratory difficulties. You notice that he has a continuous high-pitched wheeze. What does this condition indicate? Pleural inflammation Croup Fluid-blocked airways Foreign body obstruction
Foreign body obstruction A high-pitched wheeze on expiration and inspiration may indicate a foreign body obstruction. A client with fluid-blocked airways would present with a low-pitched continuous "snoring" sound on expiration and inspiration. Croup is indicated by a loud, high-pitched crowing sound on inspiration. Pleural inflammation is indicated by a low-pitched grating, rubbing sound on inhalation and exhalation.
Which of the following abnormal chest configurations are congenital deformities? Select all that apply. Barrel chest Scoliosis Funnel chest (pectus excavatum) Kyphosis Pigeon chest (pectus carinatum)
Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Funnel chest is a congenital deformity characterized by depression of the sternum and adjacent costal cartilage. Pigeon chest is a congenital deformity characterized by forward displacement of the sternum with the depression of the adjacent costal cartilage. Barrel chest occurs normally with aging. Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine. Kyphosis is an exaggerated posterior curvature of the spine associated with aging.
Located in the middle thoracic cavity, the mediastinum contains what structures? Select all that apply. Lungs Heart Pleural membranes Esophagus Trachea
Heart Esophagus Trachea The mediastinum contains the esophagus, trachea, and heart, as well as the great vessels. The lungs are situated in the pleural cavities of the thorax on either side of the mediastinum. The pleura are two serous-filled membranes that surround each lung cavity.
The nurse in the emergency department is assessing an adult client with emphysema. What symptoms of emphysema would NOT be obvious from inspection and direct observation by the nurse? Pursed-lip breathing and clubbing of fingers Hyperresonance sounds from the lungs Barrel chest Shortness of breath
Hyperresonance sounds from the lungs Clients with emphysema and COPD would have hyperresonance sounds during an assessment using percussion. These sounds would not be obvious on inspection or observation. A client with emphysema may be obviously short of breath, even at rest. A barrel chest is common in those with emphysema and would be obvious on inspection, even if the client has a shirt on. Pursed-lip breathing and clubbing of the fingers can be observed without palpation, auscultation, or percussion.
Mr. Jones is a 64-year-old man who presents to the emergency department with complaints of shortness of breath. What is the first thing you want to ascertain? Does the client have a history of stomach problems? Is the client currently taking medication? Is the condition constant or associated with activity? When was the client's last meal?
Is the condition constant or associated with activity? Determining if the condition is constant or associated with a particular activity enables you to direct the questions to gather an accurate picture of the issue at hand. Whether a client is taking medication is relevant but not primary to the cause of the client's shortness of breath. A client's stomach issues and what the client last ate are not of primary concern for someone with shortness of breath.
Identify the thoracic planes based on the imaginary lines that run vertically from the apex of the lungs to the diaphragm. Instructions: Use the dropdown menus in the left column to select the type of thoracic plane for each imaginary line in the right column. Thoracic Plane Imaginary Line Posterior Thorax Lateral Thorax Anterior Thorax Mid-sternal line Right and left mid-axillary line Vertebral spine line Right and left mid-clavicular line Right and left scapular line
Mid-sternal line- Anterior Thorax Right and left mid-axillary line- Lateral Thorax Vertebral spine line- Posterior Thorax Right and left mid-clavicular line-Anterior Thorax Right and left scapular line- Posterior Thorax
When palpating the chest of a client with shortness of breath, the nurse feels crunching under the skin of the chest wall in the mid-clavicular area. What action indicates that the nurse understands the significance of this finding? Tells the client that obesity can present as crepitus Explains that this is a normal finding Notifies the health care provider and prepares for a chest x-ray Explains that crepitus always ends in respiratory arrest
Notifies the health care provider and prepares for a chest x-ray Crepitus indicates air leaking into subcutaneous tissue. It is not a normal finding and should be reported to the health care provider. A chest x-ray may be indicated to see how the lungs are filling, and further testing may need to be done. Obesity does not cause air to leak into the tissue, but obesity may make it difficult to feel the crepitus if an air leak is present. Respiratory arrest would be considered, but crepitus does not always lead to that emergency. Assessment of other respiratory symptoms should be evaluated such as respiratory rate, skin color, and level of distress the client is experiencing.
The nurse assesses a hyperresonance sound when percussing the left side of a client's chest. What abnormal conditions are associated with this type of sound during percussion? Select all that apply. Pleural effusion Overinflation of the lungs Pneumothorax Emphysema A surgically removed lung
Overinflation of the lungs Pneumothorax Emphysema Overinflation of the lungs would cause a hyperresonance type of sound during percussion of the chest wall. Emphysema is a condition in which the lungs are in a state of overinflation, which would cause a hyperresonance sound during percussion. A pneumothorax would cause a hyperresonance sound during percussion due to the overinflation of the area around the pneumothorax. A pleural effusion is filled with fluid and would give off a dull sound during percussion. The empty space in the pleural cavity where a lung has been surgically removed would give off a dull sound during percussion.
The nurse is assessing an adult client who is complaining of chest congestion and cough. What skill(s) would the nurse expect to use to specifically assess for chest congestion? Palpation and percussion Percussion and auscultation Inspection Auscultation
Percussion and auscultation An adult complaining of chest congestion must be thoroughly assessed to determine if the congestion is upper respiratory or cardiac in origin. Percussion is helpful in assessing density or fluid-filled spaces, and auscultation assesses the air exchanged during a respiratory cycle. The combination of percussion and auscultation would make for a complete assessment of the lungs when a client complains of chest congestion.
The nurse is using inspection, palpation, percussion, and auscultation to assess the respiratory status of an older female client. What other skill(s) would be used during the assessment to ensure client satisfaction? Select all that apply. Avoiding percussion because it can be painful to female clients Providing for privacy during the exam Offering a drape to help the female client feel less exposed during the exam Avoiding a physical exam on this older female and opting for a chest x-ray Providing safety during the exam
Providing for privacy during the exam Offering a drape to help the female client feel less exposed during the exam Providing safety during the exam An older female client would be more satisfied if a complete exam were done with as much privacy as possible. Offering a sheet or drape for coverage would not only add to the client's feeling of privacy and modesty but would add warmth for an older female, who might feel cold. These small steps go far in helping to promote client satisfaction when doing a complete exam. Assessing a client's chest is a noninvasive and safe procedure, so safety is inherently provided. Avoiding percussion is unnecessary because when it is done properly, it is painless. Before opting for a chest x-ray, the cost and inconvenience involved must be considered, and it does not take the place of an exam.
When assessing an adult, what lifestyle factors would the nurse assess that directly influence the respiratory health of the adult client? Smoking history Weight Age Sexual orientation
Smoking history Smoking has a direct influence on the healthy state of an adult client's lungs and respiratory health. Factors such as age, weight, and sexual orientation may come up during the assessment but have less to do with the state of the lungs.
Which type of rhonchi is indicated by a loud, high-pitched crowing sound heard on inspiration? Wheezes Friction rub Rhonchi Stridor
Stridor Stridor is indicated by a loud, high-pitched crowing sound that occurs on inspiration and can be heard without a stethoscope. Wheezes (sibilant) are high pitched and continuous, and when severe they are heard on expiration and inspiration. Rhonchi are heard on expiration and inspiration and are low-pitched, continuous "snoring," rattling sounds. Friction rub is indicated on inhalation and exhalation by a low-pitched grating and rubbing sound.
The nurse palpates the chest wall of an adult client. The client states, "Wow, it hurts when you touch around this area." The client points to the mid-clavicular line of the right chest wall. What would be the best action by the nurse? The nurse would recognize this finding as abnormal and gently palpate the region again. The nurse would continue to palpate but with a firm hand. The nurse would ignore the complaint of pain and continue. The nurse would stop the exam.
The nurse would recognize this finding as abnormal and gently palpate the region again. It would be appropriate for the nurse to continue with gentle palpation in the area to determine the size and extent of the area of pain. The nurse would then continue with the exam by palpating the opposite side of the chest to determine if there is pain in that area. Stopping the exam or ignoring the complaint would not assist the nurse in discovering the source of the pain. Continuing with the exam would help to determine if a consultation with other health care providers is going to be needed to address this pain.
The charge nurse sends a student nurse to do a respiratory assessment of a child. What action demonstrates the student nurse's ability to properly assess the child? The student nurse inspects the child for signs of a rash. The student nurse palpates the child's extremities for lumps or masses. The student nurse places a stethoscope on each side of the child's chest and listens for breath sounds and air movement, and counts respirations. The student nurse uses percussion to assess the abdomen of the child.
The student nurse places a stethoscope on each side of the child's chest and listens for breath sounds and air movement, and counts respirations. The student nurse would use a stethoscope and auscultation to determine airflow in the lungs. Percussion on the anterior and posterior chest would be done to assess for sounds that might indicate fluid or too much air in the lungs below the chest wall. Palpation is done to assess for tenderness, masses, or lumps on the chest. The student nurse would inspect the rise and fall of the chest for the rate and depth of respirations and any signs of respiratory distress. Other things to inspect for during a respiratory exam would be color and retractions.
The nurse is interviewing and educating a client about anatomy and knows that the ribs and muscles surround the thorax, or the chest. What explanation by the nurse would describe the primary purpose of the ribs and muscles in the chest? To push the lungs during deflation To aid in exhalation To aid in inspiration To protect the lungs from external injury
To protect the lungs from external injury The main job of the ribs and muscles of the chest, or thorax, is protecting the more fragile lungs and heart from injury during daily activity. Each set of muscles assists with respiration, but the main job is to protect the lungs from puncture, bruising, and injury.
Which of the following muscles of respiration are considered accessory muscles? Select all that apply. Sternohyoid Trapezius Rectus femoris Scalene Sternocleidomastoid
Trapezius Scalene Sternocleidomastoid The scalene, sternocleidomastoid, and trapezius muscles are accessory muscles that play a major role in respiration, especially during periods of increased oxygen demand and with certain pathological conditions. The rectus femoris is a muscle in the thigh, and the sternohyoid is a muscle in the neck. Next Question
An adult client who has been visiting outside the United States mentions coughing up rust-colored sputum for several days. The nurse knows the rust-colored sputum is associated with what respiratory disease that will require further intervention? Head colds Bacterial infections Pulmonary edema Tuberculosis
Tuberculosis Rust-colored sputum is associated with tuberculosis or pneumonia. The fact that the client was out of the country and does not have any other complaints would lead the nurse to suspect tuberculosis. Pink frothy sputum is associated with pulmonary edema, white is associated with viral infections, and green or yellow is usually indicative of a bacterial infection.
The nurse is percussing the chest of an adult client and observes a lateral scar on the left posterior chest indicating a past surgical procedure. What questions would be appropriate for the nurse to ask to get a complete medical history during this exam? Select all that apply. "Did the surgery involve the lungs or the heart?" "When did the surgery occur?" "Were you placed on a respirator after the surgical procedure?" "What type of surgery did you have to your chest?" "Was the procedure inpatient or outpatient?"
"Did the surgery involve the lungs or the heart?" "When did the surgery occur?" "Were you placed on a respirator after the surgical procedure?" "What type of surgery did you have to your chest?" It would be important to know what procedure occurred and when, and whether it was performed to address a lung/thorax issue or a cardiac issue. The result of the surgery and the diagnosis would also be important. The necessity for a respirator after surgery would be important to the current assessment of the chest and respiratory status of this client.
The nurse is assessing an adult client with a cough. A positive answer to what question about the cough would require further evaluation and questioning of this client? "Do you have clear drainage from the nose?" "Are you experiencing a dry cough?" "Do you cough up blood and how often?" "Do you cough up clear sputum and how often?"
"Do you cough up blood and how often?" Many questions arise when asking a client about a cough, but the nurse would determine first and foremost whether the client is suffering from hemoptysis, or coughing up blood. This is a serious symptom and would help the nurse to determine the line of questioning to pursue. Whether the client has clear drainage from the nose or is coughing up clear sputum are the least worrisome factors to consider. The kind of cough (dry, hacking, moist, barky, or wheezy) would give the assessment a direction but is not as important as discovering if the cough produces bloody sputum.
The nurse is assessing an infant who has no obvious signs of acute illness for respiratory distress and weakness. What questions regarding health history would be important for the nurse to ask when obtaining a history from the caregiver? Select all that apply. "Have there been any injuries or trauma to the ribs in the last 24 hr?" "Have there been any signs of illness or fever in the last 48 hr?" "Is there a family history of muscle diseases or respiratory diseases, for example, muscular dystrophy or asthma?" "Is there a history of muscle weakness or respiratory distress before today?" "Does the infant have cousins who have been ill?"
"Have there been any injuries or trauma to the ribs in the last 24 hr?" "Have there been any signs of illness or fever in the last 48 hr?" "Is there a family history of muscle diseases or respiratory diseases, for example, muscular dystrophy or asthma?" "Is there a history of muscle weakness or respiratory distress before today?" If the nurse is seeing this infant for the first time for respiratory distress and weakness without signs of acute illness, it would be important to determine if the infant has a congenital disease that has led up to the weakness or if it is an acute onset of symptoms. History of genetic diseases in the family, signs of illness in the last 48 hr, and signs of any injury would be items that pertain to the current symptoms. Information about cousins does not offer any important diagnostic data.
The nurse is assessing a young adult with scoliosis. What statements indicate that the nurse understands the complexity of scoliosis? Select all that apply. "Scoliosis would be suspected if a client has a notable elevation of one scapula." "Scoliosis will cause mental delay if undiagnosed." "Scoliosis is a lateral deviation of the spine." "Scoliosis is related only to dwarfism." "The lung capacity of a client with scoliosis can be altered depending on the severity of the curvature."
"Scoliosis would be suspected if a client has a notable elevation of one scapula." "Scoliosis is a lateral deviation of the spine." "The lung capacity of a client with scoliosis can be altered depending on the severity of the curvature." Scoliosis is recognized by a lateral deviation of the spine. One scapula would be elevated, and the client can experience decreased lung capacity. Scoliosis is not limited to clients with dwarfism nor is it related to those with mental challenges. The curvature of the spine can cause pain, immobility, and respiratory compromise.
When interviewing and assessing an adult client, the nurse explains the anatomy of the lungs and why auscultation of all fields will be done. What would be appropriate for the nurse to include in client education before the exam? Select all that apply. "The right lung has three lobes: an upper, a middle, and a lower section." "Oxygen is supplied to the body through exhalation." "The left lung has only two lobes: an upper and a lower section." "It is important to avoid smoking to keep the respiratory system healthy." "One respiratory cycle is one inspiration followed by one expiration."
"The right lung has three lobes: an upper, a middle, and a lower section." "The left lung has only two lobes: an upper and a lower section." "It is important to avoid smoking to keep the respiratory system healthy." "One respiratory cycle is one inspiration followed by one expiration." To gain the client's cooperation during an exam, it is important to explain the procedure and to educate the client on wellness. If a client understands that there are three lobes on the right and two on the left, he/she will then understand the purpose of the exam. Information on smoking and on the respiratory cycle is part of wellness education and can be used to initiate conversation and questions from the client during the exam. Oxygen is not supplied to the body through exhalation.
A mother is delivering a premature infant with a gestation of 32 to 33 weeks. Some respiratory difficulty at birth is expected due to prematurity. What technique(s) would be used to assess a newborn's lungs that would also be used to assess the lungs of a child, adult, or older adult? Inspection Inspection, palpation, auscultation, percussion Palpation and auscultation Palpation
Inspection, palpation, auscultation, percussion Inspection is used to assess the chest of a client of any age. Palpation is used to assess the rise and fall of the chest wall. Percussion is used to assess for the presence of fluid versus air in the lungs and is done in a gentle manner for an infant, but the technique is the same for clients of any age. Auscultation is used to listen to the lung fields. Palpation or inspection alone is not the only way to assess an infant's lungs or respiratory status. Palpation and auscultation are only part of the full exam of an infant newborn's lungs.