Health assessment exam 2 - chapter 19

The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?

Palmar base

The nurse is preparing to auscultate the lung sounds of a client. Which sound will the nurse expect to hear over most of the client's lungs?

vesicular

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where?

Anterior

Which description of exterior landmarks indicates normal positioning of the lungs?

Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line.

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

The nurse is performing the technique shown. What is the nurse assessing?

Chest expansion

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?

Cheyne-Stokes

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?

Chronic obstructive lung disease

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?

less than 90 degrees

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

manubrium

Which pleural membrane lines the chest cavity?

parietal pleura

What action by the nurse when percussing a client's chest will help maximize the resulting vibrations?

touching the chest with only the pleximeter finger

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

tuberculosis

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

tuberculosis.

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

The nurse is assessing a client's progress in smoking cessation according to the Stages of Change Model. Which statement indicates that the client is in the Action stage?

"I just quit smoking today."

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min.

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter.

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. Percu

Asthma

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?

Bacterial infection

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system?

Bases

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea

Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.

Bronchial

Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?

Bronchial

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased o

Chronic obstructive pulmonary disease (COPD)

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?

Coarse crackles

During the assessment of a client with a pneumothorax, what change should the nurse anticipate when auscultating for fremitus?

Decreased

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

Dullness

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?

Dyspnea

A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply.

Edema Angina Orthopnea

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?

Evaluate changes in respiratory pattern and rate.

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

Forward protrusion

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

Friction rub

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel Chest

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

Funnel chest (pectus excavatum)

What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs?

Have the client cough and then listen again.

A client is concerned about developing lung cancer, as he smoked for years. He tells the nurse that he quit smoking last year but wonders if there is anything else he can do to reduce his risk for developing this disease. Which of the following should the nurse recommend?

Having his home checked for radon

The thoracic cavity contains which of the following organs? Select all that apply.

Heart Lungs Most of the esophagus

A client complains of shortness of breath for the past few days. Examination reveals late inspiratory crackles in the lower third of the chest that were not present 1 week ago. What is the most likely explanation?

Heart failure

During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on?

Heart failure induced orthopnea

A nurse inspects the anterior thorax of a client with emphysema. Which change in the thorax should the nurse recognize as normal for this client?

Horizontal position to the ribs with a costal angle of greater than 90 degrees

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment? Select all that apply.

Hyperextend the middle finger of the nondominant hand. Press the nondominant hand's distal interphalangeal joint firmly on the surface to be percussed. Avoid surface contact by any other part of the hand. Avoid having the thumb and second, fourth, and fifth fingers touch the chest.

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

Hyperresonance

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes that the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding?

Hypoventilation

A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?

Impaired Gas Exchange

A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?

In the mediastinum

A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?

Ineffective Airway Clearance

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully.

The nurse auscultates the base of the lungs to assess for what reason?

It is where fluid occurs with pulmonary edema.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung?

Move the right arm away from the body

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage.

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

Observe for the use of accessory muscles

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Observe the client's respiratory rate and pattern

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?

Opiates, which may cause hypoventilation.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through the open mouth

During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse?

Perform a focused assessment.

What color of sputum would support the diagnosis of heart failure?

Pink

The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?

Pleural effusion

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptom

Pneumonia

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

Resonance

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?

Pneumothorax

The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?

Pulmonary edema

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration.

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all lung fields

The spinous process termed the vertebra prominens is in which cervical vertebra?

Seventh

A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?

Severe brain damage

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?

Sibilant wheezes heard primarily during expiration but may also be heard on inspiration.

A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe?

Sound is louder and sounds like "A"

What is the best guide to make vertical locations on the chest?

Sternal angle

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor

When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi?

T4 spinous process

A person with a barrel chest has a problem doing what?

Taking a deep breath

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?

There is loss of involuntary respiratory control.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

Unequal expansion of the chest

The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD).

Upon inspection, the client is in the tripod position, has a barrel chest and the nails are clubbed. Crackles are heard on auscultation.

Which terms are used to identify the lobes of the right lung? Select all that apply.

Upper Lobe Middle Lobe Lower Lobe

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

a foreign body obstruction

The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the

cilia

The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which member(s) would benefit from receiving this vaccination? Select all that apply.

adult client with chronic obstructive pulmonary disease young adult client who lives alone adult client caring for children under age 5 older adult in a chronic care facility

A bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal

angle.

The apex of each lung is located at the

area slightly above the clavicle.

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

ask the client to breathe deeply through her mouth.

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

chronic bronchitis.

The nurse percusses the lungs of a client with pneumonia. What percussion note would the nurse expect to document?

dullness

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis.

Under normal circumstances, the strongest stimulus to breathe is

hypercapnia.

After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination?

hyperresonance

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

pneumonia.

The nurse is assessing a client's thorax. Which structures should the nurse identify as articulating anteriorly with the 10th rib?

previous rib cartilages

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

repeat the phrase "ninety-nine."