Prep U Ch.19 Assessing Thorax & Lungs

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

: Pleural effusion

Under normal circumstances, the strongest stimulus to breathe is

hypercapnia.

Which of the following most likely describes the sound of crackles?

-Fine: Twisting Hair through Fingers -Coarse: Velcro

Which of the following is most commonly seen in patients with scoliosis?

-Impaired Oxygenation (Spinal curvature may affect the structure of the chest wall and cause rib asymmetry. Scoliosis may affect the patient's ability to breathe and lead to impaired oxygenation.)

Which of the following most likely describes the sound of wheezes?

-Musical -High Pitched

Which of the following is most likely a risk factor associated with pneumonia?

- Immunocompromised (cannot fight off an illness as effectively, and are thereby more susceptible to infections) -Long Term Care -Older Adult

Which of the following is most likely an intervention for scoliosis?

-Surgery (Surgery is reserved for patients lateral spinal curvature beyond 40 degrees) -Body Brace (Since they do not correct spinal curve, body braces are indicated to prevent worsening spinal curve progression. The use of braces is reserved for children who are still growing and are not effective for curves greater than 45 degrees)

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

-upper lobe -lower lobe -middle lobe

When conducting the Glasgow Coma Scale on a patient, which of the following is a characteristic in the LOC (level of consciousness) assessment?

1. Delirious (Disoriented, restless, clear deficit in attention; possible incidence of hallucinations and delusions) 2. Comatose (No response to stimuli, cannot be aroused; no gag reflex or pupil response to light) 3. Obtunded (Decreased alertness, slowed motor responses; sleepiness) 4. Stuporous (Conscious but sleep-like state associated with little or no activity; only responsiveness is in reaction to pain) 5. Somnolent (Excessive drowsiness; little response to external stimuli) 6. Confused (Impaired or slowed thinking; disoriented) 7. Conscious (Normal, attentive; oriented to self, place, and mind)

Which of the following is a most likely a component of the Glasgow Coma Scale (GCS)?

1. Eye Opening (Eye opening is rated 1 to 4 points. Examples of how to rate eye opening: If your patient is spontaneously moving their eyes (4). You have to say something to your patient for them to open their eyes (3). You have to painfully stimulate them to open (2) and they do not open their eyes no matter what you do (1). 4 = spontaneous response, 3 = to voice, 2 = to pain, 1= none.) 2. Motor Response (Motor response is rated 1 to 6 points. Examples of how to rate motor response: They are moving limbs normally with no pain (6). With a painful stimulus, such as a trapezius pinch, the patient brings a hand above the clavicle to the site of physical stimulus (5). With a painful stimulus, the patient displaying normal flexion (e.g. rapid, variable, away from body) without abnormality in movement (e.g. slow stereotyped, rotation of forearm, leg extends with painful trapezius stimulus) is withdrawing in response to pain (4). If they have decorticate posturing which is curling of the limbs towards the spinal cord or "towards dee cord" as we sometimes say (3). If they have decerebrate posturing which is curling of the limbs away from the spinal cord (2). And lastly, if they have no motor response (1). 6 = normal, 5 = localized to pain, 4 = withdraws to pain, 3 = decorticate posture, 2 = decerebrate posture, 1 = none.) 3. Verbal Response (Verbal response is rated 1 to 5 points. Examples of how to rate verbal response: They participate in conversation and are oriented to time, place, and person (5). They are speaking understandably but some words are slurred or sluggish and they may seem disoriented (4). They think they are speaking but it isn't understandable (3). They only speak in sounds or grunts (2). They are completely mute, even with a painful stimulus (1). 5 = normal conversation, 4 = disoriented conversation, 3 = words, but not coherent, 2 = no words, only sounds, 1 = none.)

During your assessment of a patient with pneumonia, which of the following is most likely to be seen?

1. Shortness of Breath (SOB) (Patients with pneumonia present with shortness of breath (dyspnea), along with tachypnea (increased respiratory rate) defined as rapid, shallow respirations) 2. Wheezing or Crackles (Wheezing is heard as a high-pitched whistling sound in the lungs & Crackles are a result of fluid accumulation in the lungs) 3. Pleuritic Pain (Pleuritic pain may result from irritation and inflammation in the lungs) 4. Hypoxemia (defined as a low O2 level in the blood, occurs in pneumonia due to fluid and debris build up in the alveoli) 5. Fever 6. Cough and Sputum Production

Which of the following score ranges is best associated with patient coma using the Glasgow Coma Scale (GCS)?

8 or Less = Coma

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

At what age is it most appropriate to evaluate for scoliosis in the female population?

Adolescent Screening (Shoulder asymmetry and lateral spinal curvature is more apparent during puberty because of growth spurts. Girls should be evaluated between 10-12 years while boys should be evaluated between 13-14 years)

Which of the following is most likely the cause of wheezes?

Air Moving through Narrowed Airways

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?

Asthma

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

Chest expansion

Which of the following is most the most common way of diagnosing pneumonia?

Chest x-ray (If positive for pneumonia, the chest x-ray will show consolidation)

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

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)

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

Coarse crackles

Which of the following is most likely the cause of crackles?

Collapsed Small Airways and Alveoli "Popping Open"

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

Dullness

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

Dullness

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

Dyspnea

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

Friction rub

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

Funnel chest

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

Funnel chest (pectus excavatum)

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

Have the client cough and then listen again.

Which of the following is most likely to be seen in a patient with scoliosis?

Hump when Bending Forward

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

Impaired Gas Exchange

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

Instruct the client to cough forcefully

Which of the following is most likely the purpose of the Glasgow Coma Scale (GCS)?

LOC Assessment

Which of the following areas would you most likely hear crackles?

Lower lobes

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

Narrowing or partial obstruction of an airway passage

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

Observe for the use of accessory muscles

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

Observe the client's respiratory rate and pattern

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

One deep inspiration and expiration through the open mouth

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

A triage nurse is working in the emergency department of a busy hospital. Four clients 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 client 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 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

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

Resonance

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

Resonance over all lung fields

Which of the following best describes the anatomic abnormality present in scoliosis?

S Shaped Lateral Spinal Rotation

Which of the following score ranges is best associated with the Glasgow Coma Scale (GCS)?

Score of 3 to 15

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

Severe brain damage

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

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

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

Stridor

The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation?

Studies have indicated that there is a genetic component in the development of lung cancer.

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

Suprasternal notch

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

The thoracic cavity enlarges.

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

There is loss of involuntary respiratory control.

Which of the following areas would you most likely hear wheezes?

Throughout Lung

During your assessment of a patient with scoliosis, which of the following is most likely to be seen?

Unequal Shoulder and Scapula Height

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

Unequal expansion of the chest

Which of the following is most likely seen in patients with scoliosis?

Uneven Gait

When counseling a scoliosis patient about the use of a body brace, which of the following best describes the recommended schedule of therapy?

Worn 23 Hours/Day

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.

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

manubrium

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.