PrepU: HHA- Ch.19 Thorax & Lungs

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

-Tympany over 11th interspace, right scapular line -Hyperresonance over apices *Resonance over all lung fields* -Dullness over the lung bases 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. P396

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

-exercise-induced asthma *-a foreign body obstruction* -a severe cold -increased secretions

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 any medications on a regular basis?"* -"Have you changed your diet within the past few weeks?" -"How much do you exercise during the week?" - "Do you feel that you are under a great deal of stress?' 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.

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* 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.

The apex of each lung is located at the

* area slightly above the clavicle.*

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

*-A 64 yr old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min* -A 57 yr old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence -A 23 yr 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 yr old woman with a history of drug abuse and a heart rate of 124 beats/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 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.* -Hemoptysis is more common in children and adolescents than in older clients. -Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. -Loud and very loud percussion notes denote pathological findings 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 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.* -Assess for signs of nonproductive cough. -Assess the characteristics of sputum. -Review blood work including RBC and WBC. Observe quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

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

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

*-Pleural effusion* -Healthy lung tissue -Gastric air bubble -Chronic bronchitis When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion. Resonance is the percussion sound of healthy lung tissue. The sound of a gastric air bubble is tympany. Resonance is the percussion sound associated with chronic bronchitis

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* -Spontaneous -pneumothorax -COPD -Pneumonia 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.

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.

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* Hypoventilation A respiratory rate of 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.

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* -Sonorous wheeze -Sibilant wheeze -Fine crackles 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. P402

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 with pleuritis?

*Friction rub* Decreased breath sounds Sibilant wheeze Stridor 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.

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)* -Thoracic kyphoscoliosis -Pigeon chest (pectus carinatum) -Barrel chest

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

*Heart, Lungs, Most of esophagus* Does not contain stomach or pancreas

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.

When performing a physical examination for a client with scoliosis, which physical characteristic should the nurse expect to find during the assessment?

*Lateral deviation of the spinous processes* Lateral deviation of spinous processes in a client diagnosed with scoliosis. Non protruding, symmetrical scapulae are normal findings of the thorax. Shoulders and scapulae at a horizontal position are also a normal finding for physical assessment. Exaggerated curvature of the thoracic vertebrae is called kyphosis.

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* The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.

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* -Blockage of a respiratory passage -Fluid in the alveoli -Decreased compliance of the lungs 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. P388

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* -Percuss to determine diaphragmatic excursion -Auscultate for the presence of crackles -Palpate for tactile fremitus The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm. P394

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*

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

*Palmar base (ulnar surface)* -Fist -Pads of fingers -Dorsal hand 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. P395

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* Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

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* Asthma Pneumonia Rales 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.

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* -(COPD) -Asthma -Spontaneous pneumothorax Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies. P396

The nurse prepares to auscultate a client's lung sounds. Where on the diagram should the nurse place the stethoscope to hear sounds in the left upper lobe?

*Posteriorly, the upper lobes are auscultated above the level of the scapula.*

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

*Resonance* Hyperresonance Tympany Dullness Normal lung tissue elicits a resonance tone when percussed. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor. Tympany is elicited over air filled spaces such as puffed out check or stomach bubble. P396

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

*Seventh (C7)*

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* Renal failure Narcotic overdose Diabetic ketoacidosis The respiratory pattern observed is Biot's respirations that may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul's respirations that are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations.

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

*Stridor* Rales Crackles Wheezes 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. P402

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 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.

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.* -ask the client to breathe normally through her nose. -place the bell of the stethoscope firmly on the posterior chest wall. -auscultate from the base of the lungs to the apices.

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.* renal failure. atelectasis. congestive heart failure. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

Under normal circumstances, the strongest stimulus to breathe is

*hypercapnia.* hypoxemia. hypocapnia. pH changes.

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

*middle lobe, upper lobe, lower lobe*

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's

*pectus excavatum.* pectus carinatum (wrong) Pectus excavatum is a markedly sunken sternum and adjacent cartilages (often referred to as funnel chest). It is a congenital malformation that seldom causes symptoms other than self-consciousness.

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."* -whisper the phrase "one-two-three." -repeat the letter "E." -repeat the letter "A." P398

The nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. Which area did the nurse most likely hear these sounds?

*trachea* between the scapula bilateral lower lobes manubrium Tracheal sounds are very loud and harsh with inspiratory and expiratory sounds equal in length, over the trachea in the neck. Bronchial sounds are louder and higher in pitch and are heard over the manubrium. Bronchovesicular sounds are heard between the scapula. Vesicular sounds are heard over most of the lung fields.

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.* -bronchitis. -pulmonary edema. -asthma. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

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?

-*COPD (emphysema)* -Carcinoma of lungs -Pneumothorax -Tuberculosis An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.

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* -Ask the client how long they have to rest between activities -Report this to the health care provider immediately -Assess for symmetry of chest expansion It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency. Observing chest expansion would be appropriate assessment for a client with a pneumothorax. This finding does not need to be reported to the health care provider unless accompanied by other findings of inadequate oxygenation. Asking the client how long they need to rest between activities will not provide the nurse any objective information to differentiate the problem. P387

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

-*The thoracic cavity enlarges.* -The abdominal wall is pushed inward. -The diaphragm is seen relaxing. -Air can be heard moving out of the tracheobronchial tree. The diaphragm is the primary muscle of inspiration. When it contracts during inhalation, it descends in the chest and enlarges the thoracic cavity. At the same time, it compresses the abdominal contents, pushing the abdominal wall outward. Intrathoracic pressure decreases, drawing air through the tracheobronchial tree into the alveoli, or distal air sacs, and expanding the lungs. It is during expiration that the diaphragm relaxes.

Which accessory muscles are most important when considering inspiratory breathing needs during exercise?

-*sternocleidomastoids* -abdominal muscles -intercostal muscles -lateral neck muscles During exercise and in certain diseases, extra work is required to breathe, and accessory muscles join the inspiratory effort. The sternocleidomastoids are the most important of these, and the scalenes may become visible. Abdominal muscles assist in expiration. Intercostals and neck muscles are involved in all respirations. P399

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

-Pigeon chest -Pectoriloquy *Funnel chest* -Intercostal bulging

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?

-Reinforcing the need for a high-calorie diet T -*Teaching strategies to reduce complications of existing diagnoses* -Showing participants how to diagnose respiratory problems -Encouraging adequate rest 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 type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?

Vesicular Bronchovesicular *Bronchial* Diminished Bronchial sounds are normally heard over the main bronchi. The consolidation of the lung due to right lower lobe pneumonia may carry the bronchial sounds to the peripheral lung area. Vesicular sounds are heard from the bronchioles and lobes. Bronchovesicular lung sounds are normally heard over the main bronchi. Diminished breath sounds occur if the pneumonia has caused severe damage to the lung tissue. P397