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Assessment Chapter 19: Thorax and Lungs
Terms in this set (45)
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
The spinous process of C7.
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90
degrees. This characteristic is:
A normal finding in a healthy adult.
When assessing a patients lungs, the nurse recalls that the left lung:
consists of 2 lobes
Which statement about the apices of the lungs is true? The apices of the lungs:
Extend 3 to 4 cm above the inner third of the clavicles
During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include
the presence of:
Muffled voice sounds and symmetric tactile fremitus.
The primary muscles of respiration include the
diaphragm and intercostals
A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened
from sleep with shortness of breath. Which action by the nurse is most appropriate?
Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over
between the scapulae
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement
by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus
Is caused by sounds generated from the larynx
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results
increased density of lung tissue
The nurse is observing the auscultation technique of another nurse. The correct method to use when
progressing from one auscultatory site on the thorax to another is _______ comparison.
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are
heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that
these sounds are:
Vesicular breath sounds and normal in that location.
The nurse is auscultating the chest in an adult. Which technique is correct?
Firmly holding the diaphragm of the stethoscope against the chest
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
When the bronchial tree is obstructed
The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
decreased mobility of the thorax
When inspecting the anterior chest of an adult, the nurse should include which assessment?
Shape and configuration of the chest wall
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this
occurs in which situation?
When part of the lung is obstructed or collapsed
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath
sounds is true? Bronchovesicular breath sounds are:
Expected near the major airways.
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed
bronchioles would produce which of these adventitious sounds?
patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the
nurse will most likely observe which of these?
Anteroposterior-to-transverse diameter ratio of 1:1
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in
breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck
muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The
nurse interprets that these assessment findings are consistent with:
The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory
system of the older adult?
Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.
35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with
rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurses
preliminary analysis, based on this history, is that this patient may be suffering from
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these
findings is the nurse most likely to observe in this patient?
Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day.
The nurse recognizes that this cough may indicate:
postnasal drip or sinusitis
During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which
condition could this finding indicate?
During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?
Listening to at least one full respiration in each location
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
Chest pain that is worse on deep inspiration and dyspnea
During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:
The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling
sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
Atelectatic crackles that do not have a pathologic cause.
A patient has been admitted to the emergency department for a suspected drug overdose. His respirations
are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this
respiration pattern as which of the following?
A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other
key assessment finding would the nurse expect to find upon auscultation?
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a
normal assessment? Select all that apply.
- Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in
a very soft voice.
- When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly
distinguish what is being said.
- As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound.
Increased tactile fremitus would be evident in an individual who has which of the following conditions?
Which of the following is a clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD)?
When auscultating lung sounds, it is important for the nurse to do which of the following?
tell the patient to stop the assessment if he/she begins to feel dizzy
Inspiration is primarily facilitated by which of the following muscles?
diaphragm and intercostal
The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of older adults cause
decreased surface area for gas exchange
Stridor is a high-pitched, inspiratory crowing sound commonly associated with
upper airway obstruction
Which of the following voice sounds would be a normal finding?
THE "EEEEE" sound is clear and sounds like "eeeee"
Percussion of the chest is
helpful only in identifying surface alterations of lung tissue
An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n)
increase in estrogen
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