Health Assessment: Assessing Thorax and Lungs
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? a) "Are you taking any medications on a regular basis?" b) "Do you feel that you are under a great deal of stress?' c) "How much do you exercise during the week?" d) "Have you changed your diet within the past few weeks?"
Correct response: "Are you taking any medications on a regular basis?" Explanation: A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension. A change in diet and exercise are healthy behaviors that would not cause a persistent cough. Stress often causes shortness of breath. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 376.
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? a) 100-110 degrees b) <90 degrees c) 90-100 degrees d) >110 degrees
Correct response: <90 degrees Explanation: The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 369.
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first? a) A 23-year-old woman who had a mountain biking accident in which she suffered a neck fracture and now has numbness and tingling in her right arm b) A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min c) A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min d) A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence
Correct response: A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min Explanation: Decreased level of consciousness, respiratory rate above 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency). The only scenario in line with these criteria is the man with COPD. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 380.
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe? a) Spontaneous pneumothorax b) Chronic obstructive pulmonary disease (COPD) c) Asthma d) Pneumonia
Correct response: Asthma Explanation: Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be exacerbated by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with the severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). In severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these clients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 385.
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes? a) Lung cancer b) Sleep apnea c) Bacterial infection d) Emphysema
Correct response: Bacterial infection. Explanation: Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 374.
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 10 breaths per minute. The nurse knows the proper term for this rate is what? a) Hypoventilation b) Bradypnea c) Tachypnea d) Hyperventilation
Correct response: Bradypnea Explanation: A respiratory rate less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased with a decrease in depth, and with an irregular pattern. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 390.
Which of the following statements relating to assessment of the lungs and thorax is most accurate? a) Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. b) Hemoptysis is more common in children and adolescents than in older clients. c) Loud and very loud percussion notes denote pathological findings. d) Bronchitis is characterized by excess mucus production and chronic cough.
Correct response: Bronchitis is characterized by excess mucus production and chronic cough. Explanation: Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 389.
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect which of the following? a) Diabetes mellitus b) System lupus erythematosus c) Heart failure d) Chronic obstructive pulmonary disease
Correct response: Chronic obstructive pulmonary disease Explanation: The client is assuming the tripod position which is often seen in chronic obstructive pulmonary disease. A client with heart failure would most likely assume an orthopneic position to ease any breathing difficulties. The tripod position is usually not associated with diabetes or systemic lupus. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 381.
Which of the following muscles is primarily responsible for thoracic cavity enlargement? a) Sternomastoid b) Scalene c) Parasternal d) Diaphragm
Correct response: Diaphragm Explanation: The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity. (less) Reference: Chapter 19: Thorax and Lungs, p. 383.
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding? a) Dyspnea b) Shortness of breath c) Tachypnea d) Anxiety
Correct response: Dyspnea Explanation: Dyspnea is a subjective term used when the client reports labored breathing and breathlessness. This response to exercise or heavy activity is normal if it rapidly disappears upon return to rest. Difficulty breathing, in appropriate medical terminology, is not tachypnea, shortness of breath, or anxiety. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 374.
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? a) Listen again with the bell of the stethoscope b) Assess for the use of accessory muscles c) Have the client breathe through the mouth d) Instruct the client to cough forcefully
Correct response: Instruct the client to cough forcefully Explanation: When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 384.
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? a) Move from anterior to posterior on the same side b) Use the diaphragm then the bell in each location c) Instruct the client to breathe in and out rapidly through the mouth d) Listen at each site for at least one complete respiratory cycle
Correct response: Listen at each site for at least one complete respiratory cycle Explanation: The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 384.
A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body? a) At the base of the lungs b) At the level of the 8th rib on the right mid-clavicular line c) In the mediastinum d) At the level of the 12th rib on the left scapular line
Correct response: Mediastinum Explanation: The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 19: Assessing Thorax and Lungs, p. 371.
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings? a) Opiates, which may cause hypoventilation b) Opiates, which may cause hyperventilation c) Nothing, this is normal following surgery d) Anesthesia, from surgery that morning
Correct response: Opiates, which may cause hypoventilation Explanation: Opiates may reduce the ability of the brain to trigger breathing, causing hypoventilation (slow breathing). This scenario does not describe a reaction to anesthesia, and it is not a normal finding following surgery. (less) Reference: Chapter 18: Thorax and Lungs, p. 320.
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? a) Rales b) Pleurisy c) Asthma d) Pneumonia
Correct response: Pleurisy Explanation: Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 383
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? a) Resonance b) Tympany c) Hyperresonance d) Dullness
Correct response: Resonance Explanation: Normal lung tissue elicits a resonance tone when percussed. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor. Tympany is elicited over air filled spaces such as puffed out check or stomach bubble. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 387.
When percussing the posterior lung fields, which of the following findings is expected? a) Resonance over all lung fields b) Dullness over the lung bases c) Hyperresonance over apices d) Tympany over 11th interspace, right scapular line
Correct response: Resonance over all lung fields Explanation: All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 387.
A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect? a) Diabetic ketoacidosis b) Renal failure c) Severe brain damage d) Narcotic overdose
Correct response: Severe brain damage Explanation: The respiratory pattern observed is Biot's respirations that may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul's respirations that are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 390.
Which of the following occurs in respiratory distress? a) Neck muscles are relaxed. b) The client speaks in sentences of 10-20 words. c) Skin between the ribs moves inward with inspiration. d) Client torso leans posteriorly.
Correct response: Skin between the ribs moves inward with inspiration. Explanation: This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 382.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? a) Wheezes b) Stridor c) Rales d) Crackles
Correct response: Stridor Explanation: Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs. (less) Reference: Chapter 19: Assessing Thorax and Lungs, p. 389.
A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort? a) There is loss of involuntary respiratory control b) The client will respond negatively to increased stimuli c) The client's oxygen levels in the blood will be increased d) There is an increased level of carbon dioxide in the blood
Correct response: There is loss of involuntary respiratory control Explanation: The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The... (more) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 373.
A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? a) Right midclavicular line b) Sternal line c) Midaxillary line d) Vertebral line
Correct response: Vertebral line Explanation: The reference lines for the posterior thorax include the vertebral line and the right and left scapular lines. The midaxillary line is a reference line for the lateral aspect of the thorax. The right midclavicular line and sternal line are reference lines for the anterior thorax. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 19: Assessing Thorax and Lungs, p. 371.