Health Assessment Prep U Chapter 19 Assessing Thorax and Lungs

Chronic productive cough Recurrent respiratory infections Wheezing

What associated symptoms might a client with a history of chronic bronchitis have? (Mark all that apply.) Orthopnea Chronic productive cough Paroxysmal nocturnal dyspnea Recurrent respiratory infections Wheezing

Cheyne-Stokes Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure.

What type of respiratory pattern would the nurse consider normal in a client with severe heart failure? Biot's Bradypnea Kussmaul Cheyne-Stokes

Vesicular

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 client's lungs? Bronchovesicular Vesicular Bronchial Tracheal

Airway patent, breathing quiet, denies dyspnea

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care? Gas exchange with oxygen saturation greater than 85% Airway patent, breathing quiet, denies dyspnea Client maintains safety; no falls Pain level stabilized at client goal

Fremitus

A nurse asks a client to say "ninety-nine" while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for what respiratory characteristic? Fremitus Egophony Chest expansion Bronchophony

Pink

What color of sputum would support the diagnosis of heart failure? White Yellow Pink Rust

Bronchitis is characterized by excess mucus production and chronic cough. Bronchitis is marked by a chronic, productive cough that results from excess mucus production.

Which of the following statements relating to assessment of the lungs and thorax is most accurate? 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 characterized by excess mucus production and chronic cough.

parietal pleura

Which pleural membrane lines the chest cavity? parietal pleura pulmonary pleura visceral pleura thoracic pleura

11th and 12th

Which ribs are considered "floating ribs"? 11th and 12th 10th and 11th 9th and 10th 8th and 9th

pneumonia.

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. pleuritis. bronchitis. asthma.

repeat the phrase "ninety-nine."

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

Palpation The nurse should use the palpation technique to elicit crepitus. Crepitus is a crackling sensation that occurs when air passes through fluid or exudate.

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus? Palpation Auscultation Percussion Inspection

Fluid in the alveoli

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative? Fluid in the alveoli Fluid in the bronchioles Fluid in the bronchus No fluid present

Chronic obstructive lung disease

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client? Anxiety Pulmonary embolism Congestive heart failure Chronic obstructive lung disease

False

A client with lobar pneumonia would have muffled and indistinct spoken voice sounds. True False

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.

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

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

A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client? Fine crackles occurring late in inspiration Course crackles occurring from early inspiration to early expiration Sibilant wheezes heard primarily during expiration but may also be heard on inspiration Sonorous wheezes heard primarily during expiration but may be heard throughout the respiratory cycle

Hyperresonance Generalized hyperresonance may be heard over hyperinflated lungs found in clients with emphysema, a chronic lung disease.

After percussing a client's lung fields the nurse suspects a client has a chronic lung disease. What sound did the nurse hear to make this clinical determination? flat dull resonance hyperresonance

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

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 pulmonary edema. bronchitis. asthma. tuberculosis.

Observe the client's respiratory rate and pattern 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.

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

Narrowing or partial obstruction of an airway passage

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

Air Hunger Dyspnea is air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion, commonly termed shortness of breath.

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

"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?"

During a health history of the respiratory system, a client reports experiencing a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.) "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?" "Do you cough up mucus or phlegm?"

Move the right arm away from the body The right middle lobe of the lung is located in the midaxillary region and extends anteriorly. Therefore, the right middle lobe must be assessed from the anterior surface of the chest. This is best accomplished by asking the client to move the right arm away from the body and auscultating in the midaxillary area on the right.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung? Lateral with the right lung facing up Lean forward at the waist Rest the arms on the knees Move the right arm away from the body

Suprasternal notch The sternum, or breastbone, lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process. The manubrium connects laterally with the clavicles (collar bones) and the first two pairs of ribs. The clavicles extend from the manubrium to the acromion of the scapula. A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the suprasternal notch. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum.

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 Sternal angle Acromion of the scapula Xiphoid process

manubrium.

The clavicles extend from the acromion of the scapula to the part of the sternum termed the body. xiphoid process. angle. manubrium.

Evaluate changes in respiratory pattern and rate.

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

inflammation of the parietal pleura Inflammation of the parietal pleura produces pleuritic pain with deep inspiration, e.g., in pleurisy, pneumonia, and pulmonary embolism. The visceral pleura lies next to the lung, and the parietal pleura lines the inner rib cage and upper surface of the diaphragm. The visceral pleura lacks sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves.

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? ineffective innervation of the of the parietal pleura by the phrenic nerve an accumulation of fluid between the lungs and the visceral pleura inflammation of the parietal pleura an increase of sensory stimulation in the visceral pleura

Pulmonary edema

The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition? Tuberculosis Pulmonary edema Infection Atelectasis

chronic bronchitis.

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. atelectasis. renal failure. congestive heart failure.

Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment? Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. 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. Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

Funnel chest Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented.

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 Pigeon chest Intercostal bulging Pectoriloquy

Renal failure Drug overdose Increased intracranial pressure Severe congestive heart failure A regular breathing pattern characterized by alternating periods of deep, rapid breathing following by periods of apnea describes Cheyne-Stokes respirations.

The nurse notes that client's breathing pattern is regular but has periods of deep, rapid breathing followed by periods of apnea. What should the nurse consider as causing this client's breathing patterns? Select all that apply. Renal failure Drug overdose Diabetic ketoacidosis Increased intracranial pressure Severe congestive heart failure

Pleural effusion

The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse? Healthy lung tissue Gastric air bubble Emphysema Pleural effusion

Teaching strategies to reduce complications of existing diagnoses 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).

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? Encouraging adequate rest Reinforcing the need for a high-calorie diet Teaching strategies to reduce complications of existing diagnoses Showing participants how to diagnose respiratory problems

Pneumonia 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.

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 Fahrenheit. 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? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia

Chronic obstructive pulmonary disease (COPD)

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? Spontaneous pneumothorax Chronic obstructive pulmonary disease (COPD) Asthma Pneumonia

Fluid overload from elevation of the legs Patients who awaken at night with sudden shortness of breath have paroxysmal nocturnal dyspnea. The cause is fluid overload resulting from elevation of the legs, which shifts the fluid present there to the body's core. The excess fluid cannot be pumped through the heart and suddenly accumulates in the lungs, causing dyspnea.

A client comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the client asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response? Fluid overload from elevation of the legs Congestive heart failure Cardiac decompensation Fluid overload related to renal failure

Hyperresonance Hyperresonance would be noted in a client with emphysema due to air trapping.

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? Hyperresonance Dullness Resonance Tympany

Pneumothorax Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).

A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause? Pneumothorax Atelectasis Muscular weakness Asthma

Pleurisy Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing.

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 Pneumonia Asthma Rales

Heart failure Orthopnea, difficulty breathing when lying down, may be associated with heart failure. This may occur during sleep and wake the client up with severe shortness of breath.

A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process? Paroxysmal nocturnal dyspnea Sleep apnea Heart failure Upper respiratory infection

Funnel chest (pectus excavatum) Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

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? Barrel chest Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Thoracic kyphoscoliosis

In the mediastinum

A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body? At the level of the 12th rib on the left scapular line In the mediastinum At the level of the 8th rib on the right mid-clavicular line At the base of the lungs

Bacterial infection

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? Emphysema Lung cancer Sleep apnea Bacterial infection

less than 90 degrees The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema.

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle? 110 degrees 45 degrees 100 degrees less than 90 degrees

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/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.

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 A 57-year-old woman who had surgery yesterday for a small bowel obstruction with possible wound dehiscence A 23-year-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-year-old woman with a history of drug abuse and a heart rate of 124 beats/min

Observe for the use of accessory muscles 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.

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation? Auscultate for the presence of crackles Palpate for tactile fremitus Percuss to determine diaphragmatic excursion Observe for the use of accessory muscles

Bradypnea

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 Tachypnea Hyperventilation Hypoventilation

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

Palmar base 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 nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client? Dorsal hand surface Pads of fingers Palmar base Fist

diabetic ketoacidosis.

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. central nervous system injury. drug overdose. congestive heart failure.

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.

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

Heart Lungs Most of the esophagus

The thoracic cavity contains which of the following organs? Select all that apply. Heart Lungs Most of the esophagus Stomach Pancreas

hypercapnia. Under normal circumstances, the strongest stimulus to breathe is an increase of carbon dioxide in the blood (hypercapnia).

Under normal circumstances, the strongest stimulus to breathe is hypoxemia. hypocapnia. pH changes. hypercapnia.

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.

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

T4 spinous process

When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? Sternal angle T4 spinous process Suprasternal notch Midaxillary line

12th rib

When assessing the posterior chest, what is a starting point for counting ribs and interspaces? 6th rib 8th rib 10th rib 12th rib

One deep inspiration and expiration through the open mouth

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

Resonance over all lung fields All lung tissue is expected to be resonant on percussion.

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

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

Which action by a nurse demonstrates proper technique for assessment of chest expansion? Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall

The chest is measured to be deeper than it is wide. Observe the shape of the chest, which is normally wider than it is deep. The ratio of the anteroposterior (AP) diameter to the lateral chest diameter is usually 0.70-0.75 up to 0.90 and increases in cases of chronic obstructive pulmonary disease (COPD).

Which assessment observation should suggest that the client may be experiencing chronic obstructive pulmonary disease (COPD)? The trachea is displaced laterally. The chest is measured to be deeper than it is wide. There is a unilateral decrease in chest expansion. There is tenderness over rib area.

Forward protrusion A client with pectus carinatum has a forward protrusion of the sternum causing the adjacent ribs to slope backward.

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum? Sunken along with the adjacent cartilages Forward protrusion Midline and straight Horizontal sternum with increased intercostal angle

Unequal expansion of the chest Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis? The presence of crepitus on palpation A depressed sternum and cartilages Retraction of intercostal spaces Unequal expansion of the chest

Bronchial

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. Bronchovesicular Vesicular Bronchial Tracheal

The thoracic cavity enlarges.

Which observation confirms to the nurse that the client is experiencing a normal inspiration? The thoracic cavity enlarges. The abdominal wall is pushed inward. Air can be heard moving out of the tracheobronchial tree. The diaphragm is seen relaxing.

"Are you taking any medications on a regular basis?"

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