Health Assessment: Respiratory Review

The nurse documents which of the following clinical findings as stridor?

High-pitched sound on inspiration and exhalation, indicating laryngeal obstruction

This lung sound is continuous, high-pitched with musical instrument sound that is polyphonic and occurs mainly during expiration but can be present with inspiration as well?

High-pitched wheeze

The right & left bronchus along with the pulmonary artery & vein enter into the lungs at the?

Hilum

Cyanosis Signals______________?

Hypoxia

In planning care for a client with asthma, the nurse includes which nursing diagnosis?

Impaired gas exchange related to increased airway resistance

Barrel Chest

Increased anteroposterior diameter. This shape is normal during infancy and often accompanies aging and COPD

A client is brought into 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 in the cause?

Pneumothorax

unilateral impairment or lagging of respiratory movement suggest disease of the underlying lung or __________.

Pleura

accumulation of fluid between the pleurae is called a ______?

Plural Effusion

______________ delivers unoxygenated blood to the lungs.

Pulmonary artery

The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?

Pulmonary embolism

decreased level of consciousness indicates ___________________ to the brain and other disease processes.

poor oxygenation

Tactile fremitus

refers to vibrations that are transmitted through lung tissues and chest wall when a low pitched vocal sound is made

patients with severe asthma or COPD may prefer to sit leaning forward, with lips pursed during exhalation and arms supported on their knees or on a table. this is called ___________________.

tripod position

retraction is seen in severe asthma, COPD, or ________________.

upper airway obstruction.

Auditory fremitus

vocal resonance. Normal voice transmission is soft and muffled. If lung density increases (such as consolidation) sound transmission is enhanced

Fremitus decreased

when anything obstructs transmission of air/ vibrations to the viscera (e.g., obstructed bronchus, pleural effusion, pneumothorax, or emphysema)

paroxysms of coughing followed by a _________ intake of breath occur with __________.

whooping, pertussis.

Breath sounds louder when

-expiratory wheezes (asthma) -Consolidation -Compression

Kussmaul breathing

-hyperpnoea

Biot's respiration

-periodic breathing between hyperpnoea and apnoea -poor prognosis -neuron damage

Cheyne-Stokes respiration

-periodic breathing with gradual hyperpnoea/hypopnoea and apnoea -associated with dying process

Inspiration is primarily facilitated by which of the following muscles?

Diaphragm and intercostals

Fremitus increased

occurs with consolidation or compression of lung tissue (e.g., pneumonia, tumor, Atelectasis)

Crackles

Discontinuous nonmusical sounds or popping that can be inspiratory and expiratory. Small airway moisture. Does not clear with cough.

Bronchophony

"99" Sounds are louder and clearer over airless tissue (pleural effusions, thickening, consolidation)

Sarah is caring for a 73-year-old patient with COPD and he doesn't understand why he is losing weight because he eats a lot. What is Sarah's best response to this statement?

"COPD burns a lot of calories because it takes a lot of energy to breathe."

Everything below is part of the lower respiratory system EXCEPT (select-all-that-apply)?

- Larynx - Nasal cavities

Select all of the following that are considered discontinuous breath sounds:

- Pleural friction rub - Fine crackles (or Rales) - Coarse Crackles (or Rales)

Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest impeded. Several causes of this include:

- a very thick chest wall - obstructed bronchus - COPD - pleural effusion - fibrosis - pneumothorax

What associated symptoms might a patient with a history of chronic bronchitis have?

-Chronic productive cough -Wheezing -Recurrent respiratory infections

Breath sounds faint or absent when:

-air flow decreased -fluid or tissue obstruct air passage -Emphysema r/t lost elasticity and hyperventilation

Percussion over the bases of the lungs in a patient with bilateral lower lobe pneumonia, the nurse would expect to hear:

Dullness

Which ribs are considered "Floating Ribs" ?

11th & 12th

When assessing the posterior chest, what is a starting point for counting ribs and interspaces?

12th Rib

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

Dullness

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

Dullness

Are young toddler is brought into 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

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what?

Air Hunger

Gas exchange in the lungs occurs in the?

Alveolar sacs

sudden onset may indicate ______________ or pulmonary embolism (both emergencies), spontaneous pneumothorax, or anxiety.

Anaphylaxis

a 55 year old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. which of the following diagnoses are consistent with her gesture?

Angina Pectoris

These type of breath sounds are found at the site of the bronchi and are located anteriorly at the 1st and 2nd intercostal space & posteriorly in between the scapulae?

Bronchovesicular

If your patient is complaining of night sweats, weight loss, and occasional bloody sputum for 2 weeks, what might your next BEST question be?

Have you traveled outside the US recently?

The right middle lobe is auscultated with the stethoscope where?

Anteriorly on the right at the 4th intercostal space

audible wheezing indicates severe ___________.

Asthma

When auscultating the posterior part of the chest the upper lobes are found?

Between C7 to T3

Identify the location where bronchovesicular lung sounds are heard ?

Between the scapulae

The trachea splits at the _________ to form the ____________.

Carina, primary bronchi

Stridor

Continuous high frequency, high pitched musical sound produced during airflow through narrowing in upper respiratory tract. Best heard over neck inspiration, but can be heard at exhalation as well. Indicates laryngeal obstruction.

Wheezes

Continuous musical sounds that occur when bronchial airways are narrowed. Can be inspiratory and expiratory. Indicates moisture or debris in larger airway.

The nurse notes that crepitus of the thorax has been documented. The nurse validates crepitus with which finding?

Crackling sensation on the surface of the chest wall upon palpation

Pectus Excavatum (Funnel Chest)

Depression of lower portion of the sternum. Compression may cause murmurs.

A patient with lobar pneumonia would have muffled and Indistinct spoken voice sounds. True or false?

FALSE

The left lung is divided into upper, middle, and lower lobes. TRUE OR FALSE?

FALSE

During inhalation, the diaphragm contracts upward to create positive pressure in the chest which allows the body to inhale oxygen. True or False

FALSE. During inhalation, the diaphragm contracts DOWNWARD to create NEGATIVE pressure in the chest which allows the body to inhale oxygen.

Inhaled oxygen travels down through the trachea, into the right and left bronchus, then into the segmental bronchi which branches even further into the lobar bronchi. TRUE or FALSE?

FALSE. Inhaled oxygen travels down through the trachea, into the right and left bronchus, then into the LOBAR BRONCHI which branches even further into the SEGMENTAL BRONCHI.

Low-pitched wheezes are polyphonic sounds that can be cleared when coughing. TRUE or FALSE?

FALSE. Low-pitched wheezes are MONOPHONIC

The left lung has 3 lobes: left upper lobe, left middle lobe, and left lower lobe. TRUE or FALSE?

FALSE. The right lung has THREE lobes and the left lung has TWO lobes.

The left lung has three lobes and the right lung has two lobes. True or False:

FALSE. The right lung has THREE lobes and the left lung has TWO lobes.

_________________ is a sound that is heard over hyper-inflated lungs of COPD or asthma, but is not a reliable sign

Generalized hyper-resonance

You are auscultating a patient's lung sounds. During your assessment, you note there is a low-pitched harsh, grating sound that sounds like a pleural friction rub. However, you're not sure if this is a pleural friction rub or pericardial friction rub. What do you do next to determine the difference?

Have the patient hold their breath and note if the sound is still present

Who should NOT be vaccinated for the Flu?

Infants <6 months old

Rhonchi suggest secretions in __________________.

Large Airways

You document that your patient is complaining of orthopnea. You know that means they are having difficulty breathing while:

Laying down

Cough may also be a symptom of _____________________.

Left-sided heart failure

Rhonchi

Low pitch. May disappear with coughing due to clearing of obstruction (like mucous)

While assessing a patient's lung sounds you note bronchial breath sounds in the peripheral lung fields. What could this finding represent?

Lung consolidation like with pneumonia

Identify the location where vesicular lung sounds are heard ?

Over most of both lungs

Identify the location where bronchial lung sounds are heard ?

Over the manubrium

Identify the location where Tracheal lung sounds are heard ?

Over the trachea in the neck

When auscultating the anterior part of the chest, specifically the apex of the lungs, it is best to auscultate where with the stethoscope?

Slightly above the clavicle

The nurse documents versicular lung sounds upon auscultation. The nurse heard what type of sound?

Sound heard throughout inspiration and two thirds of expiration

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

Sternal angle

Pectus Carinatum (Pidgeon Chest)

Sternum is displaced anteriorly, increasing the anteroposterior diameter. Costal cartilages adjacent to the protruding sternum are depressed.

On auscultation of a patient in respiratory distress, you hear a high-pitched, harsh sound that is monophonic and is present only during inspiration. This is known as:

Stridor

When assessing posteriorly, where would the trachea bifurcate Into its mainstream bronchi?

T4 spinous process

A cough is typically a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. TRUE or False?

TRUE

A pneumothorax occurs when air leaks into the pleural space. TRUE OR FALSE?

TRUE

During auscultation, the anterior part of the chest mainly provides an assessment of the upper lobes of the right and left lungs, while the posterior part of the chest provides mainly provides an assessment of the lower lobes of the right and left lungs. TRUE or FALSE?

TRUE

During gas exchange, carbon dioxide is transported across the capillary membrane to be exhaled while oxygen is transported across the capillary membrane to attach to the red blood cells. True of False

TRUE

It has become apparent that there is not a lifetime immunity to pertussis for those who received the childhood DPT vaccine. True or false?

TRUE

Lung tissue has no pain fibers. True or false?

TRUE

Smoking is the leading cause of preventable death. TRUE OR FALSE?

TRUE

When assessing a patient with asthma, the nurse would expect to hear wheezing. True or false?

TRUE

Immunity to pertussis from childhood (DPT) vaccine has been shown to be weakening. vaccination with the ____________ is recommended.

Tdap vaccine

The inner layer that surrounds the lung itself is called the?

Visceral Pleura

When assessing the breath sounds of A newly admitted patient, the nurse notes increased transmission of Voice sounds over the right lung. What would this indicate to the nurse?

The lung has become airless

Bronchial breath sounds can be auscultated where?

Tracheal area

__________________ is a sound that suggest a large pneumothorax or possibly a large air-filled bulla in the lung.

Unilateral hyper-resonance

Which of the following interventions should the nurse include in the plan of care for the client with orthopnea?

Use pillows to prop the upper body when sleeping

These breath sounds are found anteriorly and posteriorly throughout the peripheral lung fields?

Vesicular

A patient appears in the clinic with a cough that begin 24 hours prior to coming to this visit. The nurse evaluates the patient based on the most common cause of an acute cough, which is?

Viral respiratory infection

viral upper respiratory infections are the most common cause of _____________ other causes include acute bronchitis, pneumonia, asthma, pertussis or foreign body.

acute cough

wheezes suggest narrowed airways, as in__________, __________, or ___________.

asthma, COPD, bronchitis.

lateral displacement of the trachea may be seen in pneumothorax, pleural effusion, or _________.

atelectasis

louder, clearer voice sounds are called______________.

bronchophony

anxious patients may have _________________ During both rest and exercise, and hyperventilation, or rapid shallow breathing.

episodic dyspnea

Percussion sounds

hyperresonance and tymphany least dense = more air or less compact tissue dull and flat most dense = less air, more compact tissue

Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. examples include ___________, in which the alveoli are filled with fluid.

lobar pneumonia