Health Assessment Ch.19

27. The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The nurse knows that a normal breathing rate is between approximately 10 and 20 breaths per minute, but the client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding? A) Ask the client if she has recently exerted herself. B) Report the finding to the client's primary care provider. C) Ask the client if she has smoked recently. D) Palpate the client's anterior and posterior thorax.

A

25. The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age- related changes? A) Slight kyphosis B) Inaudible posterior lung sounds C) Audible wheeze D) Asymmetrical chest expansion

A

3. The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What might the nurse expect to hear when auscultating the lungs of a client with this fluid volume deficit? A) Friction rub B) Decreased breath sounds C) Sibilant wheeze D) Stridor

A

4. A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status? A) The client will have a loss of involuntary respiratory control. B) The client will respond negatively to increased stimuli. C) The client will have greatly increased respiratory effort. D) The client will exhibit Cheyne-Stokes respirations.

A

9. A client has a history of emphysema. During the respiratory assessment, the nurse percusses the client's chest, expecting to find which of the following? A) Hyperresonance B) Dullness C) Resonance D) Tympany

A

5. During the health interview, a client tells the nurse that he ìcan't breathe all that wellî at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for which of the following health problems? A) Pneumonia B) Tuberculosis C) Bronchitis D) Heart failure

D

10. While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. Which of the following actions should the nurse do first? A) Refer the client for further medical evaluation. B) Auscultate for egophony. C) Perform bronchophony. D) Have the client cough, then listen again.

D

13. The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate? A) Biot's B) Bradypnea C) Kussmaul's D) Cheyne-Stokes

D

14. The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following should the nurse assess next? A) Lateral aspect of the thorax B) Lung volume C) Hip levels D) Spinal column

D

15. While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document which of the following? A) Vesicular breath sounds B) Bronchovesicular breath sounds C) Adventitious breath sounds D) Bronchial breath sounds

D

19. The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly? A) Left upper lobe B) Left lower lobe C) Right upper lobe D) Right middle lobe

D

1. When assessing whispered pectoriloquy, the nurse should instruct a client to do which of the following? A) Softly repeat the words ìone-two-three.î B) Say the number ìninety-nine.î C) Cough each time the stethoscope is moved. D) Say the letter ìeî until instructed to stop.

A

11. The nurse is preparing to auscultate the client's thorax. Which of the following actions is the priority during this component of assessment? A) Listen at each site for at least one complete respiratory cycle. B) Have the client breathe deeply through his or her nose. C) Encourage the client to cough before auscultating each site. D) Have the client hold the breath for a few seconds after auscultating each site.

A

21. The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs? A) The right lung has three lobes, while the left lung has two lobes. B) The lungs are structurally symmetrical but functionally differently. C) The right lung is approximately one-third larger than the left lung. D) The lower lobes of both lungs are primarily located toward the anterior chest wall.

A

17. A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? A) Midaxillary line B) Vertebral line C) Right midclavicular line D) Sternal line

B

23. During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following? A) Childhood exposure to air pollution B) History of tobacco use C) History of working in a factory or smelter D) History of recurrent lung infections

B

8. The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. The nurse should document this as which of the following? A) Limited expansion B) Normal expansion C) Hypoexpansion D) Hyperexpansion

B

12. An adult client has been diagnosed with bronchitis. Which of the following would the nurse most likely hear on auscultation? A) Sibilant wheezes B) Fine crackles C) Sonorous wheezes D) Coarse crackles

C

16. When percussing the scapula of a client, which of the following would the nurse expect to hear? A) Resonance B) Dullness C) Flatness D) Hyperresonance

C

18. The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position? A) At the level of the diaphragm B) Near the level of the eighth rib C) Slightly above the clavicle D) At about the tenth rib

C

2. When preparing to assess a client's thoracic cage, the nurse should locate which landmark when determining where to begin the assessment of the ribs and intercostal spaces? A) Scapula B) Suprasternal notch C) Sternal angle D) Sternal border

C

22. The nurse is conducting the health interview of an adult client who has sought care because of a ìwicked coughî leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask? A) ìDoes your cough often cause you to be short of breath?î B) ìDo you experience chest pain when you cough?î C) ìHow long have you been experiencing your cough?î D) ìAre you now or have you ever been a smoker?

C

28. A nurse is caring for a patient whose diagnosis of cystic fibrosis results in the production of large amounts of sticky mucus. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most plausible? A) Readiness for Enhanced Breathing Patterns B) Risk for Impaired Oral Mucous Membranes related to mouth breathing C) Ineffective Airway Clearance related to respiratory secretions D) Ineffective Breathing Pattern- Hyperventilation related to cystic fibrosis

C

6. A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about which of the following assessment findings related to the client's sputum? A) White or cream-colored B) Yellowish and foul-smelling C) Pink and frothy D) Rust-tinged

C

7. Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would recognize this as a tripod position and suspect the presence of which of the following medical problems? A) Pleural effusion B) Heart failure C) Chronic obstructive pulmonary disease D) Pneumonia

C

20. A nursing instructor is discussing cultural variations in the size of the thorax and impact on lung capacity. Which group would the instructor identify as typically having a larger thorax? A) African Americans B) Asian Americans C) Native Americans D) Caucasians

D

24. The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, ìIt shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker.î The nurse should recognize the need to teach the client about what topic? A) Strategies for making her husband quit smoking B) Genetic causes of lung cancer C) Age-related changes to respiratory function D) Health risks of secondhand smoke

D

26. While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment? A) ìWhen I say so, please exhale forcefully and hold the breath.î B) ìSay the letter 'e' and keep saying it until I tell you to stop.î C) ìBreathe in as deeply as you can and hold your breath until I say.î D) ìPlease say the number 'ninety-nine' for me.î

D

29. The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process? A) Air leaking from the alveoli into the pleural space B) Air being diverted from the trachea to the bronchi C) Air increasing in turbulence in a wide passage D) Air passing through constricted passageways

D

30. The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique? A) Keep the client's shirt or gown in place to maintain privacy. B) Begin with the bell of the stethoscope on the client's anterior chest. C) Tell the client that you will be asking him or her to breathe as quickly and deeply as possible. D) Place the diaphragm on the client's posterior chest wall.

D