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Review questions test 2

Terms in this set (40)

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect?
Asthma
Asthma impairs airway movement, which contributes to wheezes and decreased breath sounds. Tuberculosis typically is associated with a cough, fever, and night sweats.
Pneumonia is associated with a productive cough and fever. Croup is associated with labored breathing, fever, and a bark-like cough.
The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis?
Pneumonia
Dullness can be caused by consolidation.
Hyperresonance usually is percussed with this disease process.
Bronchiectasis is associated with a rounded chest wall and may be characterized by resonance or hyperresonance.
COPD typically is characterized by hyperresonance.
The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean?
The patient may have a pleural effusion.
Fluid in the pleural space can be detected by noting a difference in diaphragmatic excursion. A pneumothorax will be evidenced by decreased lung sounds and changes in percussion tone on the affected side. Measurements should be bilaterally equal.
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what? (Select all that apply.)
Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds. The chest should fully expand. Percussion tones would be resonant in the normal assessment of an adult; voice sounds would be muffled
The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ____________.
external intercostal muscles
The intercostal muscles help push the chest wall outward. The pectoralis minor muscle is considered an accessory muscle. The abdominal muscles are considered accessory muscles. The scalene muscles are considered accessory muscles.
A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects:
bacterial pneumonia.
The sputum by bacterial pneumonia also will have a foul smell. Viral infections usually are associated with the production of white or clear mucus. Sputum production with tuberculosis tends to be a rust color. Pink frothy sputum is a classic finding in patients with pulmonary edema.
The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding?
Chronic obstructive pulmonary disease
The costal angle increases because of an increased AP diameter. Pneumothorax is an acute condition that does not affect the shape of the chest. Infant respiratory distress syndrome is an acute condition that does not affect the shape of the chest. Atelectasis is an airless state of alveoli, but it will not affect the shape of the chest.
The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest?
Assessment of equal chest expansion
Thoracic expansion is assessed easily. Lung size is not approximated. Oxygenation is best determined by skin color, mental status, and lab tests. Lung sounds are assessed through auscultation.
A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding?
Narrowed airways
Air moving within narrowed bronchi creates the wheezing sound. Consolidation would cause decreased or absent breath sounds. Sputum causes rhonchi. Fluid in the alveoli causes crackles.
A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates:
a normal finding.
Bronchovesicular sounds are expected in this area of the chest. Pneumonia would cause crackles or no breathing sounds if there were consolidation. Lung cancer usually is not detected by auscultation. No breath sounds would be heard over a pleural effusion.
The nurse is listening to a patient's heart and hears an S2 sound. The S2 heart sound is caused by which of the following?
Closing of the aortic and pulmonic valves
A patient reports that he has intermittent chest pain. Which is the most appropriate question to ask next?
"What other symptoms do you have when the chest pain occurs?"
The nurse is percussing the heart. Percussion of the heart could be performed to:
estimate the heart's size and borders.
A patient complains of chest pain. Which report made by a patient would suggest to the nurse that the chest pain is cardiac in origin?
"My chest feels really tight and heavy."
A patient has 3+ pitting edema in her feet and ankles. The nurse suspects:
the patient has excess fluid in the interstitial space.
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