Chapter 16 Thorax and Lungs
Which terms are used to identify the lobes of the right lung? Select all that apply. upper lobe middle lobe lower lobe base lobe major lobe
upper lobe middle lobe lower lobe Explanation: Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle, and lower lobes. The left lung has only two lobes, upper and lower. Neither base nor major are terms used to identify the lobes of the lung. Chapter 16: Thorax and Lungs - Page 414
Which pleural membrane lines the chest cavity? parietal pleura pulmonary pleura visceral pleura thoracic pleura
parietal pleura Explanation: The thin, double-layered serous membrane that lines the thoracic cavity is called the pleura. The parietal pleura is the layer which lines the chest cavity, and the visceral pleura covers the exterior of the lungs. Chapter 16: Thorax and Lungs - Page 415 Add a Note
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. pleuritis. bronchitis. asthma.
pneumonia. Explanation: Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia. Chapter 16: Thorax and Lungs - Page 443
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 pulmonary edema. bronchitis. asthma. tuberculosis.
tuberculosis. Explanation: Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia. Chapter 16: Thorax and Lungs - Page 422
A client with lobar pneumonia would have muffled and indistinct spoken voice sounds. True False
False Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 16: Thorax and Lungs, p. 443. Chapter 16: Thorax and Lungs - Page 443
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? "Have you changed your diet within the past few weeks?" "How much do you exercise during the week?" "Are you taking any medications on a regular basis?" "Do you feel that you are under a great deal of stress?'
"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.
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 A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence 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 A 29-year-old woman with a history of drug abuse and a heart rate of 124 beats/min
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. Chapter 16: Thorax and Lungs - Page 417
A client has a nursing diagnosis of impaired gas exchange related to alveolar-capillary membrane changes. What interventions are appropriate in this situation? Select all that apply. Administer oxygen Facilitate deep breathing Use an incentive spirometer Increase fluids Reduce fever
Administer oxygen Facilitate deep breathing Use an incentive spirometer Explanation: Interventions that are appropriate for a client with impaired gas exchange related to alveolar-capillary membrane changes include administering oxygen, teaching deep breathing, and encouraging use of incentive spirometry or an inhaler. Neither increasing fluids nor reducing fever is an appropriate intervention with this nursing diagnosis. Chapter 16: Thorax and Lungs - Page 437
The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members 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 attending adult day care Adolescent client being home schooled
Adult client with chronic obstructive pulmonary disease Adult client caring for children under age 5 Older adult attending adult day care Explanation: The Centers for Disease Control and Prevention recommend the annual influenza vaccination for any adult with a chronic pulmonary condition, any adult who attends a chronic care facility, and caregivers of children younger than 5 years. The Centers for Disease Control and Prevention do not specifically identify the populations that include a young adult client who lives alone or the adolescent client being home schooled for the annual influenza vaccination, although all people wishing to reduce the risk of infection should be vaccinated. Chapter 16: Thorax and Lungs - Page 418
A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next? Ask how long ago he was diagnosed. Ask about any medications being used for hypertension. Refer him for further evaluation. Perform a complete respiratory assessment.
Ask about any medications being used for hypertension. Explanation: The nurse needs to ask the client about medications being used to treat his hypertension. Side effects of certain antihypertensive medications include persistent cough, which is of no consequence except for its annoying nature. Once this information is obtained then the nurse can gather additional information and complete the assessment to ensure that the findings are related to the medication and not another problem Chapter 16: Thorax and Lungs - Page 418-420
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding? Ask the client if she has recently exerted herself. Report the finding to the client's primary care provider. Ask the client if she has smoked recently. Palpate the client's anterior and posterior thorax.
Ask the client if she has recently exerted herself. Explanation: Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral. Palpation is unlikely to ascertain the cause of the increased respiratory rate. Smoking is a possible cause, but activity is more likely. Chapter 16: Thorax and Lungs - Page 426
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? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia
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. Chapter 16: Thorax and Lungs - Page 443
The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment? Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver. Begin above the right clavicle and percuss each section comparing the right chest with the left chest.
Begin above the right clavicle and percuss each section comparing the right chest with the left chest. Explanation: When percussing a client's anterior chest, the nurse should begin above the level of the clavicles to assess the lung apex. The nurse should assess the right lung area and then the left. The nurse should proceed in a methodical manner and assess each lung area, comparing right to left. The nurse should not percuss all areas on the right side of the chest before assessing the left chest. The nurse should not percuss all areas on the left side of the chest before assessing the right chest. The nurse should not complete the assessment of the left chest and then reverse the process, assessing upward from the liver. Chapter 16: Thorax and Lungs - Page 415
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? Bradypnea Tachypnea Hyperventilation Hypoventilation
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. Chapter 16: Thorax and Lungs - Page 426
A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern? Kussmaul's Cheyne-Stokes Eupnea Tachypnea
Cheyne-Stokes Explanation: Cheyne-Stokes respirations are described as respirations that gradually become faster and deeper than normal, then slower, alternating with periods of apnea. This pattern can be drug-induced, normal in frail elderly people while sleeping, or a sign of impending death. Kussmaul's respiratory pattern is described as faster and deeper respirations without pauses. Eupnea is a normal respiratory rate and rhythm. Tachypnea is an increased respiratory rate. Chapter 16: Thorax and Lungs - Page 441
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client? Anxiety Pulmonary embolism Congestive heart failure Chronic obstructive lung disease
Chronic obstructive lung disease Explanation: The client with COPD may describe the dyspnea as not being able to "breathe or take a deep breath." Although dyspnea is associated with anxiety, pulmonary embolism, and congestive heart failure, the shortness of breath is not described as the inability to take in a deep breath. Chapter 16: Thorax and Lungs - Page 421
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? Fine crackles Coarse crackles Sibilant wheeze Sonorous wheeze
Coarse crackles Explanation: Coarse crackles are low-pitched bubbling moist sounds that are described as separating Velcro. Fine crackles are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing. Sibilant wheezes are high-pitched musical sounds. Sonorous wheezes are low-pitched snoring or moaning sounds. Chapter 16: Thorax and Lungs - Page 431-435
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds? Coarse crackles Pleural friction rubs Sonorous wheezes Sibilant wheezes
Coarse crackles Explanation: Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound which is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration. Chapter 16: Thorax and Lungs - Page 435
Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum? Sunken along with the adjacent cartilages Forward protrusion Midline and straight Horizontal sternum with increased intercostal angle
Forward protrusion Explanation: A client with pectus carinatum has a forward protrusion of the sternum causing the adjacent ribs to slope backward. Sunken sternum and adjacent cartilages are seen in funnel chest. Midline and straight position of the sternum is the normal anatomical position. Horizontal sternum with increased intercostal angle is seen in barrel chest. Chapter 16: Thorax and Lungs - Page 432-442
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? Barrel chest Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Thoracic kyphoscoliosis
Funnel chest (pectus excavatum) Explanation: Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary. Chapter 16: Thorax and Lungs - Page 432-441
While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. What action would the nurse do first? Refer the client for further medical evaluation. Auscultate for egophony. Perform bronchophony. Have the client cough, then listen again.
Have the client cough, then listen again. Explanation: If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds would be done as part of any detailed assessment of the thorax. Chapter 16: Thorax and Lungs - Page 431
The thoracic cavity contains which of the following organs? Select all that apply. Heart Lungs Most of the esophagus Stomach Pancreas
Heart Lungs Most of the esophagus Explanation: The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus. It does not contain the stomach or the pancreas. Chapter 16: Thorax and Lungs - Page 411
A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding? Cheyne-Stokes respiration Biot's respiration Hypoventilation Bradypnea
Hypoventilation Explanation: Hypoventilation is decreased rate, decreased depth, and irregular pattern of respiration. A client with regular pattern characterized by alternating periods of deep rapid breathing followed by periods of apnea has Cheyne-Stokes respiration. A client with irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea has Biot's respiration. A client with bradypnea may have a regular respiration rate of less than 10/min. Chapter 16: Thorax and Lungs - Page 416-441
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? Listen again with the bell of the stethoscope Instruct the client to cough forcefully Have the client breathe through the mouth Assess for the use of accessory muscles
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. Chapter 16: Thorax and Lungs - Page 431-435
Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy? Dyspnea that is exaggerated by activity Knife-like pain that worsens on inspiration Throbbing pain that worsens on exhalation Dyspnea that is exaggerated by lying down
Knife-like pain that worsens on inspiration Explanation: Knife-like pain that worsens on inspiration is a characteristic finding that indicates pleurisy in the client. Pleurisy or a pleural rub is caused when the inflamed pleural surface comes in contact with each other on inspiration. Dyspnea is exaggerated by activity but is not a characteristic feature. Clients with pleurisy do not have throbbing pain. Dyspnea in pleurisy is not exaggerated by lying down. Chapter 16: Thorax and Lungs - Page 421
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. atelectasis. renal failure. congestive heart failure.
Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. Chapter 16: Thorax and Lungs - Page 442-443
The nurse is preparing to auscultate the client's thorax. What action is the priority during this component of assessment? Listen at each site for at least one complete respiratory cycle. Have the client breathe deeply through his or her nose. Encourage the client to cough before auscultating each site. Have the client hold the breath for a few seconds after auscultating each site.
Listen at each site for at least one complete respiratory cycle. Explanation: The client should breathe deeply through the mouth during thoracic auscultation. It is important to listen at each site for one complete respiratory cycle to obtain the most accurate information. The client does not need to cough or hold the breath before the nurse listens at each site. Chapter 16: Thorax and Lungs - Page 430
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? Fluid in the alveoli Blockage of a respiratory passage Decreased compliance of the lungs Narrowing or partial obstruction of an airway passage
Narrowing or partial obstruction of an airway passage Explanation: The auditory characteristics of wheezing result from narrowing of the lumen of a respiratory passage. Fluid in the alveoli results in crackles, and complete obstruction causes an absence of breath sounds. Decreased lung compliance compromises ventilation but does not necessarily result in wheezes. Chapter 16: Thorax and Lungs - Page 422
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? One quiet full inspiration through pursed lips Two full breaths every 10 seconds through the nose One deep inspiration and expiration through the open mouth Two full breaths in through the mouth and out through the nose
One deep inspiration and expiration through the open mouth Explanation: Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth. Chapter 16: Thorax and Lungs - Page 430
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 Opiates, which may cause hyperventilation Anesthesia, from surgery that morning Nothing, this is normal following surgery
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. Hypoventilation is breathing that is too shallow or too slow to meet the needs of the body. If a person hypoventilates, the body's carbon dioxide level rises. This causes a buildup of acid and too little oxygen in the blood. A person with hypoventilation might feel sleepy. Chapter 16: Thorax and Lungs - Page 416
Which action by a nurse demonstrates proper technique for assessment of chest expansion? Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath Explanation: The correct technique for assessment of chest expansion is for the examiner to place the hands on the posterior chest wall with thumbs at the level of T9 or T110 and pressing together a small skin fold. Ask the client to take a deep breath and observe the movement of the thumbs. Using the ball of the hand to feel vibration tests for tactile fremitus. Percussion of the posterior chest wall assesses for tone. The use of a stethoscope is auscultation and this technique assesses for adventitious sounds within the lungs. Chapter 16: Thorax and Lungs - Page 411-427
The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique? Keep the client's shirt or gown in place to maintain privacy. Begin with the bell of the stethoscope on the client's anterior chest. Tell the client that you will be asking him or her to breathe as quickly and deeply as possible. Place the diaphragm on the client's posterior chest wall.
Place the diaphragm on the client's posterior chest wall. Explanation: To auscultate, the nurse places the diaphragm of the stethoscope firmly and directly on the posterior chest wall, at the apex of the lung at C7. Clothing and gowns must be removed to ensure accurate assessment. The client should not be asked to breathe more rapidly than normal. Chapter 16: Thorax and Lungs - Page 428
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? Pleurisy Pneumonia Asthma Rales
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. Chapter 16: Thorax and Lungs - Page 421
During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply. Pneumonia Atelectasis Trauma Pneumothorax Emphysema
Pneumonia Atelectasis Trauma Pneumothorax Explanation: Decreased chest excursion is seen with emphysema. Asymmetrical chest movements may be due to pneumonia, pneumothorax, trauma or atelectasis. Emphysema is a lung condition that causes shortness of breath. In people with emphysema, the air sacs in the lungs (alveoli) are damaged. Over time, the inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones. Chapter 16: Thorax and Lungs - Page 427
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 Atelectasis Muscular weakness Asthma
Pneumothorax Explanation: Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD). Chapter 16: Thorax and Lungs - Page 421
When percussing the posterior lung fields, which of the following findings is expected? Hyperresonance over apices Dullness over the lung bases Resonance over all lung fields Tympany over 11th interspace, right scapular line
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. Chapter 16: Thorax and Lungs - Page 434
The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes? Slight kyphosis Inaudible posterior lung sounds Audible wheeze Asymmetrical chest expansion
Slight kyphosis Explanation: Kyphosis (an increased curve of the thoracic spine) is common in older clients. Inaudible lung sounds, wheezing, and asymmetrical expansion are considered pathologic findings in clients of all ages. Chapter 16: Thorax and Lungs - Page 442
When assessing whispered pectoriloquy, what would the nurse instruct the client to do? Softly repeat the words 'one-two-three'. Say the number 'ninety-nine'. Cough each time the stethoscope is moved. Say the letter 'e' until instructed to stop.
Softly repeat the words 'one-two-three'. Explanation: Softly whispering 'one-two-three' while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say 'ninety-nine' is used to test bronchophony. Saying the letter 'e' is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs. Chapter 16: Thorax and Lungs - Page 432
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? "Ninety nine" is soft and muffled Letter "E" is heard distinctly "1-2-3" is heard clearly Sound is louder and sounds like "A"
Sound is louder and sounds like "A" Explanation: To perform egophony, the nurse asks the client to repeat the letter "E" while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable. In areas of consolidation, such as pneumonia, the letter "E" will sound louder and sound like the letter "A". Bronchophony uses the words "Ninety nine". Whispered pectoriloquy uses the phrase "1-2-3". Egophony (British English, aegophony) is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis Bronchophony is the abnormal transmission of sounds from the lungs or bronchi. Bronchophony is a type of pectoriloquy Chapter 16: Thorax and Lungs - Page 432
A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honor student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia
Spontaneous pneumothorax Explanation: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds; on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan syndrome. Chapter 16: Thorax and Lungs - Page 443
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Stridor Crackles Wheezes Rales
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. Chapter 16: Thorax and Lungs - Page 426
A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status? The client will have a loss of involuntary respiratory control. The client will respond negatively to increased stimuli. The client will have greatly increased respiratory effort. The client will exhibit Cheyne-Stokes respirations.
The client will have a loss of involuntary respiratory control. Explanation: The brain stem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory function. Cheyne-Stokes respirations are an abnormal pattern of rhythmic breathing. The client's breathing will not be characterized by increased effort. Chapter 16: Thorax and Lungs - Page 416-441
The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following? Client is hypoventilating Client may have overdosed on narcotics The pattern is expected with this condition These are normal Kussmaul's respirations
The pattern is expected with this condition Explanation: Pleurisy creates difficulty in getting enough oxygen, and the body responds by increasing the respiratory effort (tachypnea) in an attempt to compensate. Hypoventilation or Cheyne-Stokes respiration would be noted with narcotic overdose. Kussmaul's respirations are associated with diabetic ketoacidosis. Chapter 16: Thorax and Lungs - Page 441
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? There is loss of involuntary respiratory control. The client will respond negatively to increased stimuli. There is an increased level of carbon dioxide in the blood. The client's oxygen levels in the blood will be increased.
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 client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts. Chapter 16: Thorax and Lungs - Page 416
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? The presence of crepitus on palpation A depressed sternum and cartilages Retraction of intercostal spaces Unequal expansion of the chest
Unequal expansion of the chest Explanation: Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing. Chapter 16: Thorax and Lungs - Page 427
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 increased secretions a severe cold exercise-induced asthma
a foreign body obstruction Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 16: Thorax and Lungs.
The apex of each lung is located at the level of the diaphragm. area slightly above the clavicle. level of the sixth rib. left oblique fissure.
area slightly above the clavicle. Explanation: The apex of each lung extends slightly above the clavicle. Chapter 16: Thorax and Lungs - Page 415
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should place the bell of the stethoscope firmly on the posterior chest wall. auscultate from the base of the lungs to the apices. ask the client to breathe deeply through her mouth. ask the client to breathe normally through her nose. TAKE ANOTHER QUIZ
ask the client to breathe deeply through her mouth. Explanation: To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation. Chapter 16: Thorax and Lungs - Page 430
The nurse assesses an adult client's breath sounds and hears sonorous wheezes, primarily during the client's expiration. The nurse should refer the client to a physician for possible asthma. chronic emphysema. pleuritis. bronchitis.
bronchitis. Explanation: Sonorous wheezes are often heard in cases of bronchitis. Chapter 16: Thorax and Lungs - Page 435
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. atelectasis. renal failure. congestive heart failure.
chronic bronchitis. Explanation: Labored and noisy breathing is often seen with severe asthma or chronic bronchitis. Chapter 16: Thorax and Lungs - Page 442-443
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. central nervous system injury. drug overdose. congestive heart failure.
diabetic ketoacidosis. Explanation: Kussmaul respirations are rapid, deep, and labored. They are considered a type of hyperventilation associated with diabetic ketoacidosis. Chapter 16: Thorax and Lungs - Page 441
