Health Assessment Exam 2

During a health history of the respiratory system, a patient complains of having a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.) a) "Is it continuous or intermittent?" b) "Does it wake you at night?" c) "Do you cough up mucus or phlegm?" d) "Does it occur at rest or with exercise?" e) "Does this occur at a particular time of day?"

"Does this occur at a particular time of day?" "Is it continuous or intermittent?" "Does it occur at rest or with exercise?" "Does it wake you at night?" To further assess the duration of the patient's cough, the nurse would ask if it occurs at a *particular time* of day, if it is *continuous or intermittent*, if it occurs *at rest or with exercise*, and *if it wakes the patient at night*. Asking if the patient coughs up mucus or phlegm assesses for characteristics of the symptoms.

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what? a) Air hunger b) Painful breathing c) Audible breathing d) Prolonged inspiration

b) Painful breathing

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? a) Bradypnea b) Tachypnea c) Hyperventilation d) Hypoventilation

a) 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

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? a) Evaluate changes in respiratory pattern and rate. b) Review blood work including RBC and WBC. c) Assess for signs of nonproductive cough. d) Assess the characteristics of sputum.

a) Evaluate changes in respiratory pattern and rate. 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

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis? a) Friction rub b) Sibilant wheeze c) Stridor d) Decreased breath sounds

a) 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 thoracic cavity contains which of the following organs? Select all that apply. a) Lungs b) Most of the esophagus c) Pancreas d) Stomach e) Heart

a) Lungs b) Most of the esophagus e) Heart The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus. It does not contain the stomach or the pancreas.

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) a foreign body obstruction b) increased secretions c) exercise-induced asthma d) a severe cold

a) a foreign body obstruction 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 You selected: a foreign body obstruction

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? a) Wheezes b) Stridor c) Crackles d) Rales

b) 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.

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? a) "Have you changed your diet within the past few weeks?" b) "Are you taking any medications on a regular basis?" c) "How much do you exercise during the week?" d) "Do you feel that you are under a great deal of stress?'

b) "Are you taking any medications 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

Which of the following statements relating to assessment of the lungs and thorax is most accurate? a) Moderate to severe chest pain is associated with a cardiac etiology, while mild to moderate chest pain is most often respiratory in origin. b) Bronchitis is characterized by excess mucus production and chronic cough. c) Loud and very loud percussion notes denote pathological findings. d) Hemoptysis is more common in children and adolescents than in older clients.

b) 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.

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? a) Carcinoma of the lungs b) Chronic obstructive pulmonary disease c) Tuberculosis d) Pneumothorax

b) 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

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? a) Shortness of breath b) Dyspnea c) Tachypnea d) Anxiety

b) Dyspnea 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.

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse? a) Report this to the health care provider immediately b) Observe the client's respiratory rate and pattern c) Assess for symmetry of chest expansion d) Ask the client how long they have to rest between activities

b) Observe the client's respiratory rate and pattern t 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.

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? a) Pneumonia b) Pleurisy c) Asthma d) Rales

b) Pleurisy 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 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? a) Renal failure b) Severe brain damage c) Narcotic overdose d) Diabetic ketoacidosis

b) severe brain damage 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.

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 a) asthma. b) tuberculosis. c) bronchitis. d) pulmonary edema.

b) tuberculosis. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

A nurse is auscultating the voice sounds of a client with consolidation in his left lower lobe of his lung due to tumor. Which of the following findings should the nurse expect on performing pectoriloquy? a) Sound is louder and sounds like "A." b) "Ninety-nine" is soft and muffled. c) "1-2-3" is heard clearly. d) Letter "E" is heard distinctly.

c) "1-2-3" is heard clearly. To perform whispered pectoriloquy, the nurse asks the client to whisper the phrase "one-two-three" while she auscultates the chest wall. Over areas of consolidation or compression, such as may occur with tumor, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope. To perform egophony, the nurse asks the client to repeat the letter "E" while listening with the stethoscope. Over normal lung tissue, the sound will be soft and muffled but the letter should be distinguishable. In areas of consolidation, such as pneumonia, the letter "E" will sound louder and sound like the letter "A." Bronchophony uses the phrase "Ninety-nine."

The area known as Erb's point is the third site for auscultation on the precordium. Where is it located? a) 4th right rib space b) 4th left rib space c) 3rd right rib space d) 3rd left rib space

c) 3rd right rib space

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes? a) Sleep apnea b) Lung cancer c) Bacterial infection d) Emphysema

c) Bacterial infection

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment? a) Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. b) Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver. c) Begin above the right clavicle and percuss each section comparing the right chest with the left chest. d) Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest.

c) Begin above the right clavicle and percuss each section comparing the right c 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 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. a) Tracheal b) Vesicular c) Bronchial d) Bronchovesicular

c) 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.

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? a) Fluid in the alveoli b) Blockage of a respiratory passage c) Narrowing or partial obstruction of an airway passage d) Decreased compliance of the lungs

c) Narrowing or partial obstruction of an airway passage The auditory characteristics of *wheezing result from narrowing of the lumen* of a respiratory passage. *Fluid* in the alveoli results in *crackles* Complete obstruction causes an absence of breath sounds. Decreased lung compliance compromises ventilation but does not necessarily result in wheezes.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following? a) Two full breaths every 10 seconds through the nose b) Two full breaths in through the mouth and out through the nose c) One deep inspiration and expiration through the open mouth d) One quiet full inspiration through pursed lips

c) One deep inspiration and expiration through the open mouth Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.

When percussing the posterior lung fields, which of the following findings is expected? a) Dullness over the lung bases b) Hyperresonance over apices c) Resonance over all lung fields d) Tympany over 11th interspace, right scapular line

c) Resonance over all lung fields 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.

An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is a) diets that are high in antioxidant vitamins. b) high serum level of high-density lipoproteins. c) high serum level of low-density lipoproteins. d) low-carbohydrate diets.

c) high serum level of low-density

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? a) 100-110 degrees b) 90-100 degrees c) >110 degrees d) <90 degrees

d) <90 degrees

A 25-year-old male patient is brought to the emergency department by ambulance after being involved in a motor vehicle accident. You find that he has decreased breath sounds over the left lung fields. What might you suspect is the cause? a) Asthma b) Muscular weakness c) Pneumothorax d) Atelectasis

d) Atelectasis

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? a) Hypoventilation b) Tachypnea c) Hyperventilation d) Bradypnea

d) Bradypnea 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.

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? a) Carcinoma of the lungs b) Pneumothorax c) Tuberculosis d) Chronic obstructive pulmonary disease

d) Chronic obstructive pulmonary disease 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

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? a) Refer the client for further medical evaluation b) Auscultate for egophony c) Perform bronchophony d) Have the client cough and then listen again

d) Have the client cough and then listen again abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds would be done as part of any assessment of the thorax.

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? a) Assess for the use of accessory muscles b) Have the client breathe through the mouth c) Listen again with the bell of the stethoscope d) Instruct the client to cough forcefully

d) 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

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? a) Patient B b) Patient A c) Patient D d) Patient C

d) 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.

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields? a) Dullness b) Hyperresonance c) Tympany d) Resonance

d) Resonance 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.

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the patient's lungs? a) Bronchial b) Bronchovesicular c) Tracheal d) Vesicular

d) Vesicular Vesicular breath sounds are normally heard over most of both lungs. In a young adult, this is the sound that the nurse will most likely hear when auscultating the patient's lungs. Bronchovesicular breath sounds are normally heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulas posteriorly. Bronchial breath sounds are normally heard over the manubrium but may not be heard at all. Tracheal breath sounds are normally heard over the trachea in the neck

The apex of each lung is located at the a) left oblique fissure. b) level of the diaphragm. c) level of the sixth rib. d) area slightly above the clavicle.

d) area slightly above the clavicle.

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should a) auscultate from the base of the lungs to the apices. b) ask the client to breathe normally through her nose. c) place the bell of the stethoscope firmly on the posterior chest wall. d) ask the client to breathe deeply through her mouth.

d) ask the client to breathe deeply through her mouth. To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation.

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? a) Asthma b) Chronic obstructive pulmonary disease (COPD) c) Spontaneous pneumothorax d) Pneumonia

d) pneumonia