Health Assessment Chapter 18 Thorax and Lungs

4

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? 1 Asthma 2 Atelectasis 3 Pneumonia 4 Pneumothorax

B

A common clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD) is: A. periodic breathing patterns. B. pursed-lip breathing. C. unequal chest expansion. D. hyperventilation.

3

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? 1 Atelectasis 2 Pneumonia 3 Emphysema 4 Pleural effusion

4, 6, 5, 2, 3, 1

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

3

A patient presents with Biot's respiration. Which finding will the nurse expect? 1 Breathing rate of less than 10 per minute 2 Gradual wax-and-wane pattern of respiration 3 Normal breathing interrupted by apnea 4 Normal inspiration followed by prolonged expiration

1

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? 1 Asthma 2 Bronchitis 3 Pneumonia 4 Atelectasis

B

An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n): A. compensatory increase in respiratory parenchyma. B. increase in estrogen. C. increase in surfactant. D. increase in tidal volume.

2

During an assessment, the nurse palpates rhonchal fremitus in a patient. Which condition may need to be further investigated? 1 Pneumothorax 2 Thick bronchial secretions 3 Inflammation of the pleura 4 Consolidation of lung tissue

1

During the chest assessment of a patient, which reference line does the nurse note on the posterior chest wall? 1 The midspinal line 2 The midaxillary line 3 The midsternal line 4 The midclavicular line

1

How deep can a percussion of the chest penetrate? 1 5 to 7 cm 2 7 to 9 cm 3 9 to 11 cm 4 11 to 13 cm

4

How does the nurse assess for tactile fremitus (vibratory tremors) in a patient? 1 By placing the fingertips on the sides of the neck 2 By placing the thumb on the spinous process of the patient 3 By placing warmed hands sideways on the posterolateral chest wall 4 By placing the palmar base of one hand to touch the patient's chest

4

How many thoracic vertebrae are present in the human body? 1. 5 2. 6 3. 7 4. 12

2

How much movement of the chest should normally occur during deep inspiration in an average adult? 1 1 to 2 cm 2 3 to 5 cm 3 7 to 8 cm 4 Less than 1 cm

B

Increased tactile fremitus would be evident in an individual who has which of the following conditions? A. Emphysema B. Pneumonia C. Crepitus D. Pneumothorax

D

Inspiration is primarily facilitated by which of the following muscles? A. Diaphragm and rectus abdominis B. Trapezius and sternomastoids C. Internal intercostal and abdominis D. Diaphragm and intercostal

B

Percussion of the chest is: A. a useful technique for identifying small lesions in lung tissue. B. helpful only in identifying surface alterations of lung tissue. C. is not influenced by the overlying chest muscle and fat tissue. D. normal if a dull note is elicited.

A

Stridor is a high-pitched, inspiratory crowing sound commonly associated with: A. upper airway obstruction. B. atelectasis. C. congestive heart failure. D. pneumothorax.

A

The function of the trachea and bronchi is to: A. transport gases between the environment and the lung parenchyma. B. condense inspired air for better gas exchange. C. moisturize air for optimum respiration. D. increase air turbulence and velocity for maximum gas transport.

C

The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of elderly adults cause: A. hyperventilation. B. spontaneous atelectasis. C. decreased surface area for gas exchange. D. decreased dead space.

7

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? Record your answer using a whole number. ________

1

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? 1 Diaphoresis 2 Chronic dyspnea 3 Two-pillow orthopnea 4 Paroxysmal nocturnal dyspnea

4

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? 1 Tuberculosis 2 Viral infection 3 Bacterial infection 4 Pulmonary edema

2

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? 1 Acute respiratory infection 2 Exposure to irritants at work 3 Development of postnasal drip 4 Bronchial inflammation of smokers

5, 4, 1, 3, 2

The nurse is assessing a patient who smokes two packs of cigarettes a day. Arrange the steps in order as to how the nurse should counsel and encourage the patient to stop smoking. 1. Assess the person to determine readiness to quit. 2. Arrange follow-up visits to check for any relapse. 3. Assist the person with a specific cessation plan. 4. Give clear and nonjudgmental advice how to quit. 5. Ask about the status of tobacco use at every visit.

1, 2, 4

The nurse is assessing the anterior chest of a patient. Which assessment findings need further investigation? Select all that apply. 1 The patient breathes through pursed lips. 2 The costal angle is greater than 90 degrees. 3 The facial expression is benign and relaxed. 4 The abdominal muscles indicate hypertrophy. 5 The ribs are sloping downwards symmetrically.

1

The nurse is assessing the bronchial breath sounds of a patient. Where should the nurse place the stethoscope? 1 Over the trachea and the larynx 2 Over the peripheral lung fields 3 Posterior between the scapulae 4 Anterior near the upper sternum

4, 3, 5, 2, 1

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

2

The nurse is assessing the lungs of the patient on the anterior side of the chest. Where would the nurse find the highest point of the lung? 1 It is found up to the seventh cervical vertebra. 2 It is found up to 3 to 4 cm above the clavicle. 3 It is found up to the twelfth thoracic vertebra. 4 It is found up to the sixth rib in the midclavicular line.

3

The nurse is assessing the respiratory pattern of an adult patient. Which assessment finding should the nurse document as abnormal? 1 Ratio of pulse to respirations is 4:1. 2 Respiratory depth is 500 to 800 mL. 3 Respiratory rate is 24 to 30 per minute. 4 Respiratory pattern appears to be even

4

The nurse is assessing the thorax and lungs of an infant. Which assessment finding needs further investigation? 1 The anteroposterior and transverse diameters are equal. 2 The chest circumference is 2 cm smaller than the head. 3 The chest wall is thin, with prominent ribs and xiphoid. 4 The respiration causes marked retraction of the sternum.

2

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? 1 Crackles 2 Stridor 3 Coarse rales 4 Sonorous rhonchi

4

The nurse is caring for an elderly patient. Which finding does the nurse associate with Cheyne-Stokes respiration? 1 The respiration cycle length is variable. 2 The breathing period lasts for 10 seconds. 3 Three to four respirations are followed by apnea. 4 There are periods of apnea in between normal breaths.

3

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? 1 Cervical 1 2 Lumbar 1 3 Cervical 7 4 Thoracic 12

2

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? 1 Fine crackles 2 Coarse crackles 3 Pleural friction rub 4 High-pitched wheeze

1

The nurse notices that a patient occasionally sighs when breathing. What should the nurse expect to happen as a result of sighing? 1 It expands the alveoli. 2 It leads to tachypnea. 3 It causes hypoventilation. 4 It leads to slow breathing.

1, 3, 4

The student nurse is listing the characteristics of normal breath sounds. Which characteristics of normal breath sounds should the student nurse include? Select all that apply. 1 Amplitude 2 Depth 3 Pitch 4 Quality 5 Pressure

1, 2, 5

What action should the nurse include when auscultating the anterior chest of a patient for breath sounds? Select all that apply. 1 Starts the auscultation at the apices in the supraclavicular areas 2 Auscultates and listens for one full respiration in each location 3 Examines one side completely and then examines the other side 4 Listens with a stethoscope over the breast in the female patient 5 Completes the examination by auscultating down to the sixth rib

2

What assessment finding will the nurse document in a patient with pneumonia? 1 A smooth chest expansion 2 A lag in the chest expansion 3 A palpable grating sensation 4 A slight inspiratory variation

2, 3, 5

What causes an increased risk for postoperative atelectasis in an elderly patient? Select all that apply. 1 Closure of a number of airways 2 Decrease in the ability to cough 3 Loss of protective airway reflexes 4 Decrease in the residual air volume 5 Increase in the amount of secretions

2, 3, 4

What changes occur in the respiratory system during pregnancy that the nurse would tell a pregnant patient about? Select all that apply. 1 The chest cage ligaments tighten and restrict full expansion. 2 The total circumference of the chest cage increases by 6 cm. 3 There is a decrease in the vertical diameter of the thoracic cage. 4 The patient has an increased awareness of the need to breathe. 5 The elevation of the diaphragm leads to a decrease in the tidal volume.

4

What does the term hypercapnia indicate about a patient's respiratory status? 1 Beginning of rapid, deep breathing 2 Presence of slow, shallow breathing 3 Decreased oxygen level in the blood 4 Increased carbon dioxide in the blood

1

What finding does the nurse identify as normal when assessing the chest of an elderly patient? 1 The patient has an outward curvature noted in the thoracic spine. 2 The respirations are deeper, with 40% increase in the tidal volume. 3 The costal angle is about 50% wider than seen in the younger adult. 4 The anteroposterior diameter is less than the transverse diameter.

1

What is a normal feature of the right lung that the nurse should be aware of? 1 It is shorter than the left lung. 2 It has an upper and lower lobe. 3 It is narrower than the left lung. 4 Its lobes sit as horizontal bands.

4

What is the function of the goblet cells of the lungs? 1 To enable the exchange of gases 2 To sweep away particulate matter 3 To provide space for gas exchange 4 To entrap small particulate matter

1

What is the main function of the respiratory system? 1 It helps in oxygen utilization. 2 It helps in the trapping of energy. 3 It helps in the production of carbon dioxide. 4 It helps in the movement of air in and out of the chest.

2

What should the nurse expect to assess when auscultating the lung sounds of a patient with heart failure? 1 Occasional wheezing 2 Crackles in the lung bases 3 Crackles over upper lobes 4 Bilateral expiratory wheezing

1

What should the nurse expect to feel while palpating a patient's chest wall after undergoing thoracic surgery? 1 Crepitus 2 Rhonchal fremitus 3 Decreased fremitus 4 Pleural friction fremitus

1, 4, 5

Which actions should the nurse take when doing a 6-minute walk test (6 MWT) with a patient? Select all that apply. 1 Put a pulse oximeter on the patient's finger. 2 Ask the person to walk as fast as possible. 3 Remind the patient not to stop for a rest. 4 Conduct the test in a flat-surfaced corridor. 5 Stop if oxygen saturation is less than 85%.

1, 2, 4,

Which additional muscles are involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? Select all that apply. 1 Scaleni 2 Trapezii 3 Diaphragm 4 Sternomastoids 5 Intercostal muscles

3

Which assessment finding would the nurse associate with mycoplasma pneumonia? 1 Dry cough 2 Barking cough 3 Hacking cough 4 Congested cough

3, 4, 5

Which breath sounds heard upon auscultation does the nurse consider normal? Select all that apply. 1 Crackles 2 Wheezes 3 Bronchial 4 Vesicular 5 Bronchovesicular

1, 3, 4

Which changes take place during the process of inspiration? Select all that apply. 1 The diaphragm descends. 2 The elastic recoil property acts. 3 The intercostal muscles contract. 4 The intrathoracic pressure decreases. 5 The anteroposterior diameter decreases

4

Which finding is a cause for concern after assessing a patient's respirations? 1 The patient does not make any noise while breathing. 2 The chest expands symmetrically with each inspiration. 3 The accessory muscles are not used during respiration. 4 The interspaces appear to be bulging during expiration.

1, 4, 5

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease (COPD)? Select all that apply. 1 The neck muscles appear to be hypertrophied from overwork. 2 The spinous processes appear as if they are in a straight line. 3 There are no major changes in the color of the patient's skin. 4 The patient leans forward with the arms against the knees. 5 The anteroposterior and transverse diameter are both equal.

C

Which of the following is not included in the definition of the thoracic cage? A. Sternum B. Ribs C. Costochondral junction D. Diaphragm

C

Which of the following pairs correctly expresses the relationship to the lobes of the lungs and their anatomic position? A. Upper lobes—lateral chest B. Upper lobes—posterior chest C. Lower lobes—posterior chest D. Lower lobes—anterior chest

B

Which of the following voice sounds would be a normal finding? A. The voice transmission is distinct and sounds close to the ear. B. The "eeeee" sound is clear and sounds like "eeeee." C. The whispered sound is transmitted clearly. D. Whispered "1-2-3" is audible and distinct.

4

Which part of the lungs is assessed on the posterior chest? 1 Most of the upper lobes 2 Most of the middle lobe 3 None of the middle lobe 4 All parts of the lower lobes

2, 3, 4

Which structures will the nurse assess when looking at the mediastinum? Select all that apply. 1 Lungs 2 Heart 3 Trachea 4 Esophagus 5 Pleural cavities

3

While assessing a patient, the nurse hears a cracking or grating sound on auscultation. What abnormality is suspected in the patient? 1 Wheezes 2 Crackles 3 Friction rub 4 Atelectasis

2

While assessing the tactile fremitus (vibratory tremors) of the patient, the nurse learns that the fremitus is decreased. Which disorder may be diagnosed in the patient? 1 Bronchitis 2 Pleural effusion 3 Lobar pneumonia 4 Pulmonary infarction