Chapter 19: Assessing Thorax and Lungs

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

tuberculosis

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

upper lobe middle lobe lower lobe

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

chronic obstructive pulmonary disease

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

chronic obstructive pulmonary disease An increase in the anterior posterior diameter is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.

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

cilia

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

coarse crackles 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 that 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.

The nurse notes that a client has the thoracic structure shown. How should the nurse document this finding?

crooked upper spine: Thoracic kyphoscoliosis

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

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

diaphragm

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

evaluate changes in respiratory pattern and rate

When percussing the scapula of a client, which of the following would the nurse expect to hear?

flatness Normally, percussion over the scapula elicits flat tones. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air, such as in emphysema or pneumothorax.

A patient comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the patient asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response?

fluid overload from elevation of the legs Patients who awaken at night with sudden shortness of breath have paroxysmal nocturnal dyspnea. The cause is fluid overload resulting from elevation of the legs, which shifts the fluid present there to the body's core. The excess fluid cannot be pumped through the heart and suddenly accumulates in the lungs, causing dyspnea.

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

friction rub In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngospasms, such as croup.

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

funnel chest Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented. Pigeon chest or pectus carinatum occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air. Whispering pectoriloquy is identfied when sounds are louder and clearer than the wispered sounds.

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

have the client cough and then listen again

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

heart lungs most of the esophagus

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process?

heart failure

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

one deep inspiration and expiration through an open mouth

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

repeat the phrase "ninety-nine"

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

resonance over all lung fields

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

seventh

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?

severe brain damage

the apex of each lung is located at the

slightly above the clavicle

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen at each site for at least one complete respiratory cycle

A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?

Patient C

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

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

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

are you taking medication on a regular basis 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.

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

ask the client to breathe deeply through her mouth

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

bradypnea

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 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.

Which ribs are considered "floating ribs"?

11th and 12th Note that the costal cartilages of the first seven ribs articulate with the sternum; the cartilages of the 8th, 9th, and 10th ribs articulate with the costal cartilages just above them. The 11th and 12th ribs, the "floating ribs," have no anterior attachments. The cartilaginous tip of the 11th rib usually can be felt laterally, and the 12th rib may be felt posteriorly. On palpation, costal cartilages and ribs feel identical.

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 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.

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

Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line. Using exterior landmarks picture the lungs and their fissures and lobes on the chest. Anteriorly, the apex of each lung rises approximately 2 cm to 4 cm above the inner third of the clavicle. The lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line. Posteriorly, the lower border of the lung lies at about the level of the T10 spinous process. On inspiration, it descends farther.

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section comparing the right chest with the left chest. When percussing a patient'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.

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

Bronchitis is characterized by excess mucus production and chronic cough. Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.

The nurse is assessing a client's breath sounds. Where should the nurse expect to hear bronchovesicular sounds?

Bronchovesicular breath sounds are heard between the scapula on the posterior chest.

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

Chronic obstructive pulmonary disease (COPD)

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea is a subjective term used when the client reports labored breathing and breathlessness. This response to exercise or heavy activity is normal if it rapidly disappears upon return to rest. Difficulty breathing, in appropriate medical terminology, is not tachypnea, shortness of breath, or anxiety.

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

instruct the client to cough forcefully 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.

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

narrowing or partial obstruction of airway passage

Which of the following would be best for a nurse to use when assessing for fremitus in a client?

palmar base (ulnar surface) The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. The dorsal surface of the hand is used to assess temperature. The fist is used in blunt percussion. Fingerpads are used for fine discrimination such as pulses, texture, and size.

The thin double-layered serous membrane that lines the chest cavity is termed

parietal pleura

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

pneumonia

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

softly repeat the words "1,2,3" 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.

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

stridor 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.

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

teaching strategies to reduce complications of existing diagnoses Health promotion activities focus on preventing disease from developing (primary prevention), screening to identify conditions at an early curable stage (secondary prevention), and reducing complications of existing or established medical diagnoses (tertiary prevention).

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

the thoracic cavity enlarges

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

Funnel chest (pectus excavatum) 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.

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

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

bronchial These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains 'ee' to & 'aa' changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall.