TEST 4: Jarvis Chapters 18 & 19

A student nurse attends a lecture on the position of the heart. Which statement by the student nurse indicates effective learning?

"The position of the heart depends on the age of the patient." The position of the heart in an adult is different from that of an infant. The position of the heart in the chest is more horizontal in the infant than in the adult. The apex is higher, and is located at the fourth left intercostal space. It reaches the adult position when the child reaches the age of 7.

Which statement describes the structure of the lungs?

"The right lung is shorter and wider than the left lung." The lungs are paired, but are not symmetric structures. The right lung is shorter than the left lung because of the liver present below it. The right lung is wider because the heart bulges to the left. The right lung has three lobes, whereas the left lung has two lobes.

A young adult patient comes to the emergency department complaining of difficulty breathing. The person appears cyanotic and uses accessory neck muscles. The nurse hears audible wheezing. There is decreased tactile fremitus with hyperresonant sounds on percussion. Normal breath sounds are distant and hard to hear because of wheezing. Which disorder does the nurse suspect?

*Asthma* is an allergic hypersensitivity characterized by bronchospasm and inflammation, edema in the walls of the bronchioles, and secretion of highly viscous mucus into the airways. These greatly increase the airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness. During a severe attack, there is an increased respiratory rate, shortness of breath with audible wheezes, use of accessory neck muscles, and cyanosis.

Which assessment finding will the nurse document for a patient with chronic respiratory disease?

*Clubbing of the distal phalanx* occurs with chronic respiratory disease following the growth of vascular connective tissue.

The nurse is caring for a patient who reports lower-extremity cramping during exercise. The nurse records the blood pressure in the upper extremities at 20 mm Hg greater than that of the lower extremities. The nurse also notices diminished femoral pulses in the patient. Which complication should the nurse expect to find in the patient?

*Coarctation of the aorta* is a congenital condition which involves the severe narrowing of the descending aorta. This condition decreases the amount of blood flow to the lower extremities; therefore, it decreases the blood pressure more in the lower extremities than in the upper extremities. The patient may have leg cramping during strenuous activities.

The nurse is giving a lecture about adventitious sounds to nursing students. Which sound should the nurse compare to the opening of a Velcro fastener?

*Coarse crackles* are loud, low-pitched bubbling and gurgling sounds. These sounds start during early inspiration and may be present in expiration.

Which murmurs are caused by an obstruction of the flow of blood into the ventricles?

*Diastolic rumbles* occur due to filling of the ventricles at a low pressure due to the obstruction of the flow of blood into the ventricles.

A middle-aged patient comes to the clinic and states, "I can't get my breath when I walk." The nurse notes that the patient has a barrel chest and is using the accessory muscles to breathe. The patient's respiratory rate is 28. On palpation, there is a limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder does the nurse suspect?

*Emphysema* is caused by the destruction of the pulmonary connective tissues. This increases airway resistance, especially on expiration, producing a hyperinflated lung and an increase in lung volume. Such patients have a barrel chest and use accessory muscles to breathe. Shortness of breath occurs especially due to physical exertion; therefore, respiratory distress is also commonly observed. Tachypnea or high respiratory rate is also recorded in such patients. Decreased tactile fremitus is found on palpation. Auscultation reveals decreased breath sounds and prolonged expiration.

The nurse is taking care of a patient with visible apical impulse in the sixth left intercostal space lateral to the midclavicular line. On palpation, the nurse finds that the impulse is approximately 4 cm in diameter and is more forceful than usual. Which disorder does the nurse suspect?

*Left ventricular hypertrophy* (LVH) is the thickening of the myocardium of the left ventricle. In such a disorder, a sustained apical impulse with increased force occurs. The duration is also increased, but no change in location is seen.

After auscultating the precordium of a patient, the nurse suspects that the patient has pulmonic hypertension. Which finding would the nurse observe in the patient?

*Lifting impulse in the left sternal border* A lifting impulse occurs with right ventricular hypertrophy, as in pulmonic disease and pulmonic hypertension. This may be due to the presence of an enlarged right ventricle, which results in the posterior rotation of the left ventricle.

While assessing a patient, the nurse hears a cracking or grating sound on auscultation. What abnormality is suspected in the patient?

*Palpable friction rub* is produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. Then, the opposing surfaces make a coarse grating sound when rubbed together during breathing.

The patient reports having a sudden stabbing pain below the sternum, in the upper back, and in the neck. During the assessment, the nurse also finds that the patient has a fever, joint pains, and a dry cough. What condition is most consistent with these findings?

*Pericarditis* refers to the inflammation of the pericardium. Fever, dry cough, and joint pains are subjective symptoms of pericarditis. Sudden pain in the substernal region that radiates to the trapezius muscle and is present in the upper back is a sign of pericarditis.

A college student comes to the emergency room with complaints of a sudden, sharp pain on the right side, and shortness of breath. The right side of the chest is not moving with inspiration. The patient's trachea is deviated toward the left; there is no tactile fremitus on the right. The nurse hears hyperresonant percussion sounds on the right and resonant sounds on the left. There are no breath sounds heard on the right. Which disorder does the nurse suspect?

*Pneumothorax* is a condition in which free air in the pleural space causes partial or complete lung collapse. In pneumothorax, unequal chest expansion is seen with decreased tactile fremitus. The trachea shifts to the unaffected side. Breath sounds are decreased or absent, and percussion reveals hyperresonance.

Which condition would cause a patient to have a diminished first heart sound of S1 due to more forceful atrial contractions?

*Severe hypertension* leads to an increase in the force of the atrial contractions, while pushing blood into the noncompliant ventricles. This may result in delayed ventricular contraction and a diminished S1.sound.

The nurse is caring for a child with acute epiglottitis. The child has a high-pitched, monophonic, inspiratory crowing sound. What term should the nurse use to document this finding?

*Stridor* is a continuous high-pitched, monophonic, inspiratory crowing sound. The sound originates in the larynx or trachea from an upper airway obstruction due to swollen and inflamed tissues. The sound is louder in the neck than over the chest wall.

The nurse is caring for a child who often has cyanotic episodes while crying. The nurse notices that the child uses the squatting posture during exertion. While assessing the child, the nurse finds that the sound A2 is louder than P2. Which complication would the nurse expect in the child?

*Tetralogy of Fallot* is a congenital heart condition in which four abnormalities occur together. These include right ventricular stenosis, right ventricular hypertrophy, ventricular septal defect, and overriding aorta. Tetralogy of Fallot causes mixing of oxygenated and deoxygenated blood in the left ventricle and reduces oxygenation of the tissues, which may result in cyanosis.

Which component of the jugular venous pulse corresponds to the opening of the tricuspid valve?

*Y descent* indicates passive ventricular filling and opening of the tricuspid valve.

When auscultating the heart of a newborn within 24 hours after birth, the examiner hears a continuous sound that mimics the sound of a machine. This finding most likely indicates:

*an expected sound caused by nonclosure of the ductus arteriosus* The murmur of a patent ductus arteriosus is a continuous machinery murmur, which disappears by 2 to 3 days.

Which of the following is not included in the definition of the thoracic cage?

*costochondral junction* The thoracic cage comprises the sternum, ribs, vertebrae, and diaphragm.

The jugular venous pressure is an indirect reflection of the:

*heart's efficiency as a pump* If the pressure is elevated, heart failure is suspected.

Percussion of the chest is:

*helpful only in identifying surface alterations of lung tissue* Percussion detects only the outer 5 to 7 cm of tissue; it does not penetrate to reveal any change in density deeper than that. Resonance is a low-pitched, clear, hollow sound that predominates with percussion of healthy lung tissue.

An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n):

*increase in estrogen* The increase in estrogen level during pregnancy relaxes the chest cage ligaments. This allows an increase in the transverse diameter of the chest cage by 2 cm, and the costal angle widens.

While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient?

*pathologic S4* Murmurs can be heard in the left intercostal space in the patient with pulmonic stenosis. Calcification of the pulmonic valve in the patient with pulmonic stenosis may result in the enlargement of the right ventricle. The fourth heart sound, S4, occurs after the diastole due to resistance of the ventricles to fill with blood. It commonly occurs in the presence of an enlarged right ventricle.

A common clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD) is:

*pursed lip breathing* By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse.

A bruit heard while auscultating the carotid artery of a 65-year-old patient is caused by:

*turbulent blood flow through the carotid artery* A bruit indicates atherosclerotic narrowing of the vessel.

Stridor is a high-pitched, inspiratory crowing sound commonly associated with:

*upper airway obstruction* from swollen, inflamed tissues or a lodged foreign body

The nurse is assessing the chest of a patient for symmetric expansion. Arrange the steps in the order in which the nurse would do the assessment.

1. Put the hands sideways on the posterolateral chest wall. 2. Have the thumbs meet together at the T9 or T10 level. 3. Slide hands medially to pinch the skin between the thumbs. 4. Ask the patient to inhale and take a deep breath. 5. The nurse should note thumb movement

A nurse is describing fetal lung development to a pregnant patient during an exam. Arrange the order in which lung development takes place from the embryonic stage to the birth of the infant.

1. The primitive lung bud emerges during fetal life. 2. The conducting airways develop as in the adult. 3. The surfactant is present in adequate amounts. 4. The lungs form about 70 million primitive alveoli. 5. The blood supply is detached from the placenta. 6. The blood gushes into the pulmonary circulation.

How many thoracic vertebrae are present in the human body?

12

How much movement of the chest should normally occur during deep inspiration in an average adult?

3 to 5 cm

How deep can a percussion of the chest penetrate?

5 to 7 cm

Which heart rate would be found in an infant with bradycardia?

A heart rate of less than 60 beats/minute indicates bradycardia in the infant.

The nurse finds a lift while assessing a patient presented for a cardiac checkup. Which statement describes a lift?

A lift is a sustained thrust of the ventricle of the heart. A lift is also called a heave. It occurs due to right ventricular hypertrophy and is felt as a diffused lifting impulse during the ventricular systole at the left lower sternal border. A lift may be associated with the retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle.

Which statement describes a thrill?

A thrill is a *palpation of the chest*. It is likened to the throat of a purring cat. The thrill signifies turbulent blood flow and directs the nurse to locate the origin of loud murmurs.

Which conditions may cause a pathologic S3, or a ventricular gallop?

A ventricular gallop occurs due to an increase in fluid volume. *Anemia*, *pregnancy*, and *hyperthyroidism* may increase cardiac output in the patient. Therefore, the nurse can hear ventricular gallop in the pregnant patient or in the patient with anemia or hyperthyroidism.

After conducting a cardiac examination, the nurse concludes that the patient has normal cardiopulmonary functioning. Which findings enabled the nurse to reach this conclusion?

Absence of cardiac murmur S2 is louder at the base of the heart The absence of cardiac murmur indicates that the patient has intact cardiac valves. The first heart sound (S1) and second heart sound (S2) are heart sounds that are produced by the opening or closing of the heart valves; it is normal for S2 to be louder when auscultating at the base of the heart.

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs?

After auscultation in the supine position, the nurse should have the patient *roll onto the left side*; the examiner should listen at the apex with the bell for the presence of any diastolic filling sounds (i.e., S3 or S4) or murmurs that may be heard only in this position. The examiner should have the patient sit up and lean forward; the examiner should auscultate at the base with the diaphragm for a soft, high-pitched, early diastolic murmur of aortic or pulmonic regurgitation

While assessing a patient, the nurse finds elevated jugular venous pressure, ventricular gallop, and a pulse deficit. The diagnostic results of the patient indicate that the diameter of heart is 5 cm. Which complication does the nurse suspect in the patient?

An elevated jugular venous pressure, pulse deficit, and a heart diameter of greater than 4 cm indicate the patient has *heart failure*.

What abnormality would the nurse expect in a patient with kyphosis?

An exaggerated posterior curvature of the thoracic spine

What method should the nurse use to detect a pericardial friction rub?

Auscultate with the diaphragm of a stethoscope. Inflammation of the pericardium leads to a friction rub. The sound is high-pitched and scratchy, like sandpaper being rubbed. It is best heard using the diaphragm of a stethoscope, with the person sitting up and leaning forward, holding the breath in expiration.

Where is the heart located in the human body?

Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line

The nurse is caring for a patient with a regular breathing rate of eight breaths per minute. What is the most likely cause for this condition?

Bradypnea, or slow breathing, is the regular breathing rate of less than 10 breaths per minute. It may be caused by *drug-induced depression* of the respiratory center in the medulla.

What should the nurse document as a normal finding when auscultating a toddler's chest for breath sounds?

Bronchovesicular breath sounds in the peripheral lung fields

How are the intercostal spaces of the thorax numbered?

By the ribs present above the spaces

The nurse is assessing the jugular pulse of a patient. Which jugular pulse component reflects ventricular contraction?

C wave The jugular pulse, a waveform that moves backward, is caused by events upstream. The C wave occurs due to ventricular contraction. It is the backflow from the bulging upward of the tricuspid valve when it closes at the beginning of the ventricular systole.

The nurse is examining the most prominent spinous process in the vertebral column of a patient who may have spondylosis. Which posterior vertebral landmark is the nurse examining?

Cervical 7

While auscultating the precordium of a patient, the nurse hears the first heart sound (S1). What causes the first heart sound?

Closing of the mitral valve

What should the nurse expect to assess when auscultating the lung sounds of a patient with heart failure?

Crackles in the lung bases

While assessing the tactile fremitus of the patient, the nurse learns that the fremitus is decreased. Which disorder may be diagnosed in the patient?

Decreased fremitus occurs when the bronchus of the patient is obstructed. Any barrier that comes between the sound and the palpating hand of the nurse will decrease the fremitus. When there is air outside the lung in the chest cavity, it prevents lung expansion and decreases the tactile fremitus. *Pleural effusion, thickening pneumothorax, or emphysema* may be responsible for this.

The nurse is assessing a patient for shortness of breath (SOB). What term should the nurse use to document night sweats associated with shortness of breath?

Diaphoresis

Which changes take place during the process of inspiration?

During inspiration, the contraction of the bell-shaped *diaphragm causes the chest cavity to descend and flatten*. *Contractions of the intercostal muscles* during inspiration lift the sternum and elevate the ribs, making them more horizontal. Inspiration increases the size of the thoracic cavity and *decreases the intrathoracic pressure*.

Which of the following cardiac alterations occurs during pregnancy?

During pregnancy the blood volume increases by 30% to 40%; this creates an *increase in stroke volume and cardiac output* and an increased pulse rate of 10 to 15 beats per minute. The arterial *blood pressure decreases* in pregnancy as a result of peripheral vasodilation.

The nurse is planning the cardiac assessment of a patient. Which patient positions are necessary during this assessment?

During the assessment of the carotid artery, the patient should be placed in the *sitting* position. In order to assess the jugular veins and the precordium, the patient should rest in the *supine* position with the head and chest elevated between 30 and 45 degrees. The *left lateral recumbent* position is used to measure the blood pressure in a pregnant patient. This finding is significant in determining the functionality of the heart during pregnancy.

While auscultating the chest, the nurse asks the patient to phonate a long "ee-ee-ee-ee" sound. Through the stethoscope, the nurse hears a long "aaaaa" sound. Which voice sound is present?

Egophony

Which of the following voice sounds would be a normal finding?

Egophony: the "eeeee" sound is clear and sounds like "eeeee." Bronchophony: normal voice transmission is soft, muffled, and indistinct Whispered pectoriloquy: whispered sound is faint, muffled, and almost inaudible.

When would the nurse perform the abdominojugular test?

If the venous pressure is elevated or if the nurse suspects heart failure When performing the abdominojugular test, sustained venous distention is suggestive of right-sided heart failure.

While assessing a patient, the nurse finds that the liver and the jugular vein have become enlarged. The nurse could best hear the soft and pansystolic heart murmur at the lower right and left sternal borders. Which disorder does the nurse suspect?

In *tricuspid regurgitation*, backflow of the blood occurs through the incompetent tricuspid valve into the right atrium. This results in engorged pulsating jugular veins and an enlarged liver. A soft, blowing, pansystolic heart murmur can be best heard at the right and the left lower sternal border. The murmur increases with inspiration.

What does the term hypercapnia indicate about a patient's respiratory status?

Increased carbon dioxide in the blood (normal stimulus for breathing)

Increased tactile fremitus would be evident in an individual who has which of the following conditions?

Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar *pneumonia*).

What is the main function of the respiratory system?

It helps in oxygen utilization.

The nurse starts to count the ribs of the patient from the angle of Louis. Which statement precisely describes the "angle of Louis"?

It is the *articulation of the manubrium and the body of the sternum*. It is a useful place to start counting the ribs. The angle of Louis helps the nurse localize a respiratory finding horizontally. It is continuous with the second rib.

What finding does the nurse identify as normal when assessing the chest of an elderly patient?

Kyphosis, or an outward curvature of the thoracic spine, is a normal finding in elderly patients.

After reviewing the medical history of a female patient, the nurse suspects that the patient is at risk for developing cardiovascular complications. Which findings led the nurse to this conclusion?

LDL level of 150 mg/dL Body mass index of 30 kg/m2 Total cholesterol of 240 mg/dL High levels of low-density lipoprotein (LDL or "bad" cholesterol) slowly block arteries, which can result in myocardial infarction and stroke. LDL levels above 130 are considered high. A body mass index of greater than 25 kg/m2 indicates obesity in the patient. The obese patient is at high risk for developing heart disease. Total blood cholesterol is a measure of LDL cholesterol, HDL cholesterol, and other lipid components. It should be less than 200 mg/dL.

Which clinical findings does the nurse observe in the patient with mitral regurgitation?

Mitral regurgitation is the condition in which the mitral valve does not close properly. Due to improper closure of mitral valve, the patient may have *diminished S1* and *accentuated S2*. *Apical impulse displaces down* due to volume overload.

The nurse notices that a patient occasionally sighs when breathing. What should the nurse expect to happen as a result of sighing?

Occasional sighing punctuates the normal breathing pattern and helps to *expand the alveoli*. Frequent sighing may indicate emotional dysfunction, leading to hyperventilation and dizziness.

The nurse is assessing the bronchial breath sounds of a patient. Where should the nurse place the stethoscope?

Over the trachea and the larynx These sounds have a high pitch, loud amplitude, with a harsh or hollow tubular quality.

The nurse is going through the electrocardiogram (ECG) report of a patient complaining of chest pain. Which section of the electrocardiograph indicates atrial depolarization?

P wave During atrial depolarization and contraction, electrodes placed on the surface of the body record a small burst of electrical activity lasting for a fraction of a second. This is the P wave. It is a recording of the spread of depolarization through the atrial myocardium from the beginning to the end.

The nurse instructs a student nurse to palpate the carotid artery of a patient. Which action made by the student nurse needs correction?

Palpating both carotid arteries at once Palpating both carotid arteries at the same time will compromise arterial blood supply to the brain.

The nurse is determining diaphragmatic excursion in a patient. Which action should the nurse perform?

Percuss up and down to locate the diaphragm on inspiration and expiration.

While assessing the cardiac health of a middle-aged patient, which finding would the nurse consider abnormal?

Presence of a third heart sound The S3 indicates decreased compliance of the ventricles, and it may be the earliest sign of heart failure.

The nurse is assessing the respiratory pattern of an adult patient. Which assessment finding should the nurse document as abnormal?

Respiratory rate is 24 to 30 per minute. The normal respiratory rate for an adult is 10 to 20 breaths per minute. An increase in the respiratory rate is normal with fear, fever, or exercise. It may also indicate respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

Which of the following guidelines may be used to identify which heart sound is S1?

S1 coincides with the carotid artery pulse

What is the characteristic feature of the third heart sound, S3?

S3 is a ventricular filling sound and it occurs due to the backward flow of blood into the left atrium. The third heart sound occurs in the apex or *left lower sternal border*, and the sound does not change with respiration.

Which statement best describes the semilunar valves?

Semilunar valves lie between the ventricles and the great vessels. Each valve has three cusps that look like half moons.

While assessing a patient who has fever, cough, and myalgia, the nurse confirms that the patient has pneumonia. Which other symptom would the nurse expect to find in the patient?

Stabbing pain located in the chest with a cough on one side due to inflammation of the pleura

Which blood vessel drains the blood from the head and upper extremities?

Superior vena cava

A patient presents with Biot's respiration. Which finding will the nurse expect?

The breathing pattern in Biot's respiration is irregular. A series of three to four normal respirations is followed by a period of apnea. The length of the cycle is variable and lasts for 10 seconds to 1 minute. It is generally seen in patients with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.

Which assessment findings should the nurse identify with a barrel chest?

The chest appears as if held in continuous inspiration. The ribs appear to be horizontal in relation to the spine. The anteroposterior diameter is equal to the transverse diameter.

Which extra sounds may occur in early diastole?

The early diastolic stage involves the closing of the semilunar valves and opening of the atrioventricular (AV) valves. The opening of the AV valves is normally silent, but in cases of stenosis, more intra-atrial pressure is required to open the AV valve. Therefore, the opening of the atrioventricular valve makes a noise referred to as an *opening snap*. The opening of a ball-in-cage mitral prosthesis in early diastole gives an opening click termed as *mitral prosthetic valve sound*.

What is the characteristic of the first heart sound in the patient who has a complete heart block?

The first heart sound will be of *varied intensity* because the atria and the ventricles beat independently in the patient with complete heart block.

How would the nurse describe an innocent murmur?

The innocent murmur is generally soft, midsystolic, short, and has a vibratory or musical quality. It is Grade 2.

Which finding is a cause for concern after assessing a patient's respirations?

The interspaces appear to be bulging during expiration. Bulging of the interspaces during expiration indicates the presence of trapped air. It may be forced expiration associated with emphysema or asthma.

While assessing the jugular venous pressure of a patient, the nurse finds that the pressure is elevated. Which observation is consistent with this conclusion?

The level of pulsation is 3 cm above the sternal angle while at 45 degrees. The normal jugular pressure should be less than or equal to 2 cm above the sternal angle when the patient is elevated at 30 degrees, and the value should be 3 cm or less when elevated at 45 degrees. Therefore, the jugular venous pressure of 3 cm above the sternal angle when elevated at 45 degrees indicates that the pressure is increased.

Inspiration is primarily facilitated by which of the following muscles?

The major muscle responsible for inspiration is the *diaphragm*. *Intercostal muscles* lift the sternum and elevate the ribs, making them more horizontal; this increases the anteroposterior diameter.

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease (COPD)?

The neck muscles are *hypertrophied in COPD from aiding in harder work* due to forced respirations across the obstructed airways. The patient has difficulty breathing in the upright position and prefers to sit in the tripod position: the patient *leans forward with the arms braced against the knees, chair, or bed*. This gives the necessary leverage so that the abdominal, intercostal, and neck muscles can aid in expansion. The patient has a barrel chest with an *equal anteroposterior and transverse diameter*. This occurs from the hyperinflation of the lungs.

The nurse is assessing a newborn immediately after birth. The newborn has a heart rate of 105 with good respiratory effort. There is some flexion of the extremities and some resistance to extension. The newborn grimaces in response to a catheter in the nares. The body is pink and the extremities are pale. What is the Apgar score for the newborn?

The newborn's heart rate is above 100, so the score is 2. The respiratory effort is good, so the score is 2. The score is 1 each for muscle tone, reflex irritability, and color. The total score is 2 + 2 + 1 + 1 + 1, which is equal to *7*.

What action should the nurse include when auscultating the anterior chest of a patient for breath sounds?

The nurse should begin *auscultating at the apices in the supraclavicular areas*. This allows the nurse to listen from the very top of the lungs. The nurse must *listen to one full respiration in each location* for any adventitious lung sounds, because they may be heard in inspiration, expiration, or both. The nurse *moves downward all the way down to the sixth rib* to hear the bases of the lungs. The nurse must examine the chest from side to side while moving down to compare the sounds in the right and left lung. The nurse must not place the stethoscope directly over the female patient's breast, because this will prevent the nurse from clearly hearing the lung sounds. The nurse must listen directly over the chest wall after displacing the breast for accurate results.

The nurse is preparing a patient for cardiac assessment. Which interventions should the nurse follow while assessing?

The nurse should* ask the patient to sit during the carotid artery assessment* because the seated position allows proper exposure of the neck. The nurse places the *patient in the supine position while auscultating the precordium* to obtain accurate jugular venous pressure. The nurse needs to *maintain a warm room temperature during the cardiac assessment* because a cold room may make the patient uncomfortable, and shivering interferes with auscultating heart sounds.

Which actions should the nurse take when doing a 6-minute walk test (6 MWT) with a patient?

The nurse uses a pulse oximeter on the patient's finger to monitor the oxygen saturation. The nurse should do the test on a flat-surfaced corridor with controlled environment. The test must be stopped if the patient's oxygen saturation drops below 85% or if extreme breathlessness occurs. The nurse must ask the patient to set his or her own pace to cover as much ground in 6 minutes. The patient can be assured that it is fine to slow down or stop for rest at any time.

How does the nurse assess for tactile fremitus in a patient?

The nurse uses either the palmar base of the fingers or the ulnar edge of one hand to touch the patient's chest. The patient is asked to repeat resonant phrases such as "ninety-nine" or "blue moon." These phrases generate strong vibrations.

What is indicated in a patient with pathologic S3?

The pathologic S3 indicates decreased compliance of the ventricles; it may be the earliest sign of heart failure.

The nurse is assessing the anterior chest of a patient. Which assessment findings need further investigation?

The patient breathes through pursed lips to exhale slowly. This allows the pressure in the bronchial tree to remain positive and fewer airways collapse. It is an indication of chronic obstruction pulmonary disease (COPD) and needs further investigation. If the costal angle is greater than 90 degrees, the patient has a barrel chest. A barrel chest is the result of equal anteroposterior-to-transverse diameter and ribs that are horizontal. This condition must be investigated further, because it often occurs with chronic emphysema and asthma as a result of the hyperinflation of lungs. Hypertrophy of the abdominal muscles occurs in chronic emphysema and needs further investigation.

What causes an increased risk for postoperative atelectasis in an elderly patient?

The patient has a greater risk for postoperative atelectasis and infection from a decreased ability to cough, a loss of protective airway reflexes, and increased secretions. The costal cartilages become calcified and respiratory muscle strength declines, leading to a decrease in the ability to cough. The loss of protective airway reflexes leads to the inability of clearing the increased amount of secretions.

A patient complains of sudden pain in the shoulder and the lateral region of the chest. The nurse finds that the patient has acute dyspnea and a cough. What conclusion could the nurse draw from these findings?

The patient has a pneumothorax. It is also associated with referred shoulder pain, acute dyspnea, and cough. It is caused due to accumulation of air in the pleural space.

The nurse is caring for a patient who reports pain in the right side of the abdomen and right shoulder. The patient reports that the pain is most severe after eating a fatty meal. What should the nurse infer from these findings?

The patient has cholecystitis. Cholecystitis is the inflammation of the gallbladder, which results in the accumulation of bile. Bile helps in the digestion of fats in the small intestine, so a patient with cholecystitis may not be able to digest the fats and this may produce pain in the right upper abdominal region, which radiates to the right shoulder.

The nurse is caring for a patient who has pain in the substernal region. The patients states, "I feel like some object is blocking my throat." After doing an assessment, the nurse finds that the pain may be caused by gastrointestinal complications. What condition may be causing the patient's symptoms?

The patient may have esophageal spasms. The squeezing of the muscles of the esophagus may prevent food from reaching the stomach, leaving it stuck in the esophagus. This may lead to the feeling in the patient that some object is obstructing the throat or esophagus. This causes pain in the substernal region.

Which patients are at highest risk for developing cardiac disease?

The patient with diabetes mellitus The patient with vitamin D deficiency The patient with increased body weight Diabetes mellitus causes damage to the large blood vessels, which nourish the heart. Therefore, it increases risk of cardiac disease. Vitamin D deficiency decreases the levels of calcium and results in weakness of the heart muscle. Obesity leads to an increase in the cardiac output and cardiac workload.

A nursing instructor is describing the pleurae to a class of nursing students. Which statements should the nursing instructor include?

The pleurae are *thin, slippery, serous membranes* that form an envelope *between the lungs and the chest wall*. The pleural cavity is a space which may be filled only with a few milliliters of lubricating fluid that allow the lungs to slide smoothly and noiselessly up and down during normal respiration. The pleural cavity normally has a *negative pressure*, or vacuum, which holds the lungs tightly against the chest wall.

Which of the following pairs correctly expresses the relationship to the lobes of the lungs and their anatomic position?

The posterior chest is almost all lower lobe. The anterior chest contains mostly upper and middle lobe with very little lower lobe.

The parent of a child worries about the humming sound heard in the child's chest. After assessing the child, the nurse informs the parents that the child is healthy. Which finding does the nurse observe in the child to support this conclusion?

The presence of a *continuous, low-pitched, soft sound at the medial third of the clavicle*, especially on the right or over the upper anterior chest, indicates a venous hum. It occurs due to the turbulence of blood flow in the jugular venous system and is common in healthy children.

While auscultating an infant's heart sounds, the nurse notices that the infant has a fixed split S2, P2 louder than A2, and a medium-pitched systolic murmur, which is clearly heard in the second left interspace. What is the most likely reason for this condition in the infant?

The presence of an *abnormal opening in the atrial septum* or atrial septal defect will increase blood flow through the pulmonic valve. This may lead to an earlier closure of the aortic valve than the pulmonic valve, resulting in a fixed split S2. The heart sound that occurs after the pulmonic valve closure, or P2, is louder than A2 due to the increased blood flow through the pulmonic valve. The infant with an atrial septal defect may have a medium pitched systolic cardiac murmur.

The nurse is assessing the thorax and lungs of an infant. Which assessment finding needs further investigation?

The respiration causes marked retraction of the sternum. Marked retractions of the sternum and intercostal muscles indicate increased inspiratory efforts and the need to be investigated further. It may indicate atelectasis, pneumonia, asthma, or an acute airway obstruction.

What is a normal feature of the right lung that the nurse should be aware of?

The right lung is shorter than the left lung because of the presence of the liver, which sits just under the right lung. The right lung has three, not two, lobes: an upper, middle, and lower lobe.

What changes occur in the respiratory system during pregnancy that the nurse would tell a pregnant patient about?

The total circumference of the chest cage increases by 6 cm. The transverse diameter of the chest cage increases by 2 cm and the costal angle widens. Although the diaphragm is elevated, it is not fixed. The enlarging uterus elevates the diaphragm by 4 cm, leading to a decrease in the vertical diameter of the thoracic cage. Physiologic dyspnea may occur in early pregnancy, leading to an increased awareness of the need to breathe. An increase in estrogen levels during pregnancy relaxes the chest cage ligaments, allowing the chest cage to increase in the horizontal diameter. Although the diaphragm is elevated, it moves with breathing even more during pregnancy. This movement results in a 40% increase in tidal volume.

The nurse is caring for a patient with small amounts of tissue consolidation in the lungs. What will the nurse hear through the stethoscope when the patient whispers a phrase?

The voice can be heard similar to a *whisper in the ears*. The condition is said to be whispered pectoriloquy.

The nurse is caring for an elderly patient. Which finding does the nurse associate with Cheyne-Stokes respiration?

There are periods of apnea in between normal breaths. The breathing periods last from 30 to 45 seconds, with periods of apnea lasting for about 20 seconds.

What are chordae tendineae?

These are collagenous fibers that anchor the leaflets of the atrioventricular valves. These prevent the prolapse of the atrioventricular valves into the atria during ventricular contraction.

During an assessment, the nurse palpates rhonchal fremitus in a patient. Which condition may need to be further investigated?

Thick bronchial secretions Fremitus is a palpable vibration. When the patient is asked to say something, the sounds generated from the larynx are transmitted through the patent bronchi and the lung parenchyma to the chest wall, and can be felt as vibrations.

What assessment finding will the nurse document in a patient with pneumonia?

a lag in the chest expansion

Which part of the lungs is assessed on the posterior chest?

all parts of the lower lobes The lower lobes begin at T3 or T4 and their inferior border reaches down to the level of T10 on expiration and T12 on inspiration.

The ability of the heart to contract independently of any signals or stimulation is due to:

automaticity

The leaflets of the tricuspid and mitral valves are anchored by __________________ to the _________________, which are embedded in the ventricular floor.

chordae tendineae; papillary muscles

The first heart sound (S1) is produced by the:

closure of the AV valves

What should the nurse expect to feel while palpating a patient's chest wall after undergoing thoracic surgery?

crepitus (coarse, crackling sensation palpable over skin surface) Crepitus occurs when air escapes from the lung and enters the subcutaneous tissue after open thoracic surgery.

The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of elderly adults cause:

decreased surface area for gas exchange

What is the thin layer of endothelial tissue that lines the inner surface of the heart and the valves called?

endocardium

The nurse is assessing a patient who reports a cough that always occurs in the daytime or early evening but subsides at night. What is the most probable cause for the cough?

exposure to irritants at work

Which assessment finding would the nurse associate with mycoplasma pneumonia?

hacking cough

Which structures will the nurse assess when looking at the mediastinum?

heart, trachea, esophagus, great vessels

The nurse is caring for a patient who has an incompetent tricuspid valve. Where should the nurse observe the palpable thrill in this patient?

left lower sternal border

The student nurse is listing the characteristics of normal breath sounds. Which characteristics of normal breath sounds should the student nurse include?

pitch, amplitude, duration, quality, normal duration

Which sign would be present in a patient with atherosclerosis?

presence of bruit sound Atherosclerotic disease causes turbulence in the blood flow and results in a bruit sound.

The nurse is assessing a patient who coughed up pink, frothy sputum several times during the day. What is the probable cause for this finding?

pulmonary edema

Which term can be used to describe the pacemaker of the heart?

sinoatrial (SA) node

During the chest assessment of a patient, which reference line does the nurse note on the posterior chest wall?

the midspinal or vertebral line

What is the function of the goblet cells of the lungs?

to secrete mucus that entraps particulate matter

The function of the trachea and bronchi is to:

transport gases between the environment and the lung parenchyma

The semilunar valves separate the:

ventricles from the arteries