HA MIDTERMS Flashcards
1.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?
Dyspnea
2.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?
Severe brain damage
3.Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Listen at each site for at least one complete respiratory cycle
4.62-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?
Chronic obstructive pulmonary disease (COPD)
5.When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
One deep inspiration and expiration through an open mouth
6.When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields
7.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?
Evaluate changes in respiratory pattern and rate
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
Patient C
9.Which terms are used to identify the lobes of the right lung? Select all that apply
upper lobe, middle lobe, lower lobe
10.The nurse is assessing a client’s breath sounds. Where should the nurse expect to hear bronchovesicular sounds?
between the scapula on the posterior chest.
11.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
Foreign body obstruction
12.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
13.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
Tuberculosis
14.The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
Ask the client to breathe deeply through her mouth
15.Which observation confirms to the nurse that the client is experiencing a normal inspiration?
The thoracic cavity enlarges
16.Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
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 Farenheit. Her blood pressure and pulse 17.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?
Pneumonia
18.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?
chronic obstructive pulmonary disease
19.The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the
Cilia
20.The nurse notes that a client has the thoracic structure shown. How should the nurse document this finding?
crooked upper spine: Thoracic kyphoscoliosis
21.A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client’s respiratory effort?
there is loss of involuntary respiratory control
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?
heart failure
23.Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm
24.Auscultation of a 23-year-old client’s lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
narrowing or partial obstruction of airway passage
The spinous process termed the vertebra prominens is in which cervical vertebra?
Seventh
26.The thoracic cavity contains which of the following organs? Select all that apply.
Heart, lungs, most of the esophagus
27.Adventitious sounds are heard when auscultating a client’s lungs. Which of the following would the nurse do first?
have the client cough and then listen again
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?
are you taking medication on a regular basis
29.The nurse is preparing to percuss a patient’s anterior chest area. Which approach will the nurse use for this assessment?
begin above the right clavicle and percuss each section comparing the right chest with the left chest.
30.patient 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 patient asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse’s best response?
fluid overload from elevation of the legs Patients who awaken at night with sudden shortness of breath have paroxysal 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.
31.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.
Bronchial
32.Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough.
33.A nurse auscultates a client’s lungs and hears fine crackles. What is an appropriate action by the nurse?
instruct the client to cough forcefully
34.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
35.A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
Stridor
36.When percussing the scapula of a client, which of the following would the nurse expect to hear?
Flatness
37.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?
bradypnea
38.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?
teaching strategies to reduce complications of existing diagnoses
39.the apex of each lung is located at the
Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line.
40.Which description of exterior landmarks indicates normal positioning of the lungs?
the inner third of the clavicle.
41.What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?
friction rub
42.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?
chronic obstructive pulmonary disease rub
43.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”
44.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
45.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?
Funnel chest (pectus excavatum)
46.During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
coarse crackles
47.Which ribs are considered “floating ribs”?
11th and 12th
48.Which of the following would be best for a nurse to use when assessing for fremitus in a client?
palmar base (ulnar surface)
49.When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?
softly repeat the words “1,2,3”
50.High-pitched, short, popping sounds
Crackles (fine)
51.Forward protrusion of the sternum
wheeze (sibilant)
52.High-pitched musical sound
wheeze (sibilant)
An increase in carbon dioxide in the blood
Hypercapnea.
54.Low-pitched, bubbling, moist sounds
Crackles (coarse)
55.Low-pitched snoring or moaning sounds
Wheeze (sonorous)
56.Difficulty breathing when lying supine
Orthopnea
57.Markedly sunken sternum and adjacent cartilage
Pectus excavatum
58.Low-pitched, dry, granting sounds
Pleural Friction Rub
59.the clavicles extend from the acromion of the scapula to the part of the the sternum is termed
Manubrium
60.The apex of each lung is located at the
slightly above clavicle
61.The thin double-layered serous membrane that lines the chest cavity is termed
parietal pleura.
The nurse assesses an adult client’s thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client’s
pectus excavatum.
63.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
64.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?
Evaluate changes in respiratory pattern and rate
65.Crepitus
A “crackling” sensation
66.Forward protrusion of the sternum
Pectus carinatum
67.While assessing an adult client, the client tells the nurse that she “has had difficulty catching her breath since yesterday.” The nurse should assess the client further for signs and symptoms of
Infection
68.The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation?
Studies have indicated that there is a genetic component in the development of lung cancer
69.The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by
asking the client to exhale forcefully and hold his breath
70.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.
71.The nurse assesses an adult client’s breath sounds and hears sonorous wheezes, primarily during the client’s expiration. The nurse should refer the client to a physician for possible
bronchitis.
1.at puberty, the female breasts enlarge in response to
Estrogen and Progesterone
2.elevated sebaceous glands, known as montgomery glands are found darkly pigmented are surrounding the nipple of the mammary gland
Montgomery glands
3.fibrous tissue that supports the glandular tissue of the breasts fibrous glands extending vertically from the breast surface to attach on the chest wall muscles
Areola
4.the size and shape of the breasts in females are related to
cooper ligaments
5.the functional part of the breast that allows milk production consists of tissue termed
Fatty tissue
