Jarvis Chapter 19: Thorax & Lungs Flashcards
The nurse is teaching the nursing students to palpate the vertebra prominins when beginning posterior thoracic assessment of a patient. The students will:
a. Look for the spinous process of C7
b. Usually not be able to palpate this on most individuals
c. Find the interior border of the scapula
d. Locate this next to the manubrium of the sternum.
a. Look for the spinous process of C7
When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is:
a. Observed in patients with kyphosis.
b. Indicative of pectus excavatum
c. A normal finding in a healthy adult.
d. An expected finding in a patient with a barrel chest.
c. A normal finding in a healthy adult.
When assessing a patient’s lungs, the nurse recognizes that the left lung:
a. consists of two lobes.
b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
a. consists of two lobes.
The nurse landmarks the apices of the lungs to:
a. Be at the level of the second rib anteriorly
b. Extend 3 to 4 cm above the inner third of the clavicles.
c. Be located at the sixth rib anteriorly and the eighth rib laterally.
d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line.
b. 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:
a. Costal angle
b. Sternal angle
c. Xiphoid process
d. Suprasternal notch
b. Sternal angle
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
a. Adventitious sounds and limited chest expansion.
b. Increased tactile fremitus and dull percussion tones..
c. Muffled voice sounds and symmetrical tactile fremitus.
d. Absent voice sounds and hyper-resonant percussion tones.
c. Muffled voice sounds and symmetrical tactile fremitus.
The primary respiratory muscles engaged in normal inspiration include the:
a. Diaphragm and intercostals
b. Sternomastoid and scalene
c. Trapezius and rectus abdominis
d. External obliques and pectoralis major.
a. Diaphragm and intercostals
During assessment of the patient’s posterior chest for lung sounds, the nurse will auscultate the right lung for:
a. Apex of the lung
b. Upper and lower lobes
c. Lower lobe, because the upper lobe is too small
d. Upper, middle, and lower lobes
b. Upper and lower lobes
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?
a. Obtain a detailed health history of the patient’s allergies and a history of asthma.
b. Recommend that the patient sleep on his or her right side to facilitate east of respirations.
c. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea
d. Assure the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week.
c. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea
When assessing tactile fremitus, the nurse normally feels tactile fremitus most intensely:
a. Between the scapula
b. Third intercostal space
d. Fifth intercostal space, midaxillary line
d. Over the lower lobes, posterior side.
a. Between the scapula
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”…
a. Is caused by moisture in the alveoli
b. Indicates that air is present in the subcutaneous tissues
c. is caused by sounds generated from the larynx
d. reflects the blood flow through the pulmonary arteries.
c. 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 from:
a. Shallow breathing
b. Normal lung tissue
c. Decreased adipose tissue
d. Increased density of lung tissue
d. 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.
a. Side-to-side
b. Top-to-bottom
c. Posterior-to-anterior
d. interspace-by-interspace
a. Side-to-side
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 these sounds as:
a. Normally auscultated over the trachea
b. Bronchial breath sounds, which are normal in that location.
c. Vesicular breath sounds, which are normal in that location.
d. Bronchovesicular breath sounds, which are normal in that location.
c. Vesicular breath sounds, which are normal in that location.
The nurse is auscultating the chest of an adult patient. Which technique is correct?
a. Instructing the patient to take deep, rapid breaths
b. Instructing the patient to breath in and out through his/her nose.
c. Firmly holding the diaphragm of the stethoscope against the patient’s skin.
d. Lightly holding the bell of the stethoscope over the gown to avoid friction.
c. Firmly holding the diaphragm of the stethoscope against the patient’s skin.
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:
a. dullness
b. tympany
c. resonance
d. hyper-resonance
a. dullness
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
a. When the bronchial tree is obstructed
b. When adventitious sounds are present
c. In conjunction with widespread pectoriloquy
d. In conditions of consolidation, such as pneumonia
a. When the bronchial tree is obstructed
The nurse knows that a normal findings when assessing the respiratory system of an older adult is:
a. Increased thoracic expansion
b. decreased mobility of the thorax
c. decreased anteroposterior diameter
d. Bronchovesicular breath sounds throughout the lungs.
b. decreased mobility of the thorax
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had “a runny nose for a week.” When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse’s next action should be to:
a. Assure the mother that these signs are normal symptoms of a cold.
b. Recognize that these are serious signs, and contact the physician.
c. Ask the mother if the infant has had trouble with feedings.
d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.
b. Recognize that these are serious signs, and contact the physician.
The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal reaction occurs. Significant retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis, therefore a referral to a physician is warranted.
When assessing the repiratory system of a 4-year-old child, which of these findings would the nurse expect?
a. Crepitus palpated at the costochondral junctions.
b. No diaphragmatic excursion as a result of a child’s decreased inspiratory volume.
c. Presence of bronchovesicular breath sounds in the peripheral lung fields
d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest.
c. Presence of bronchovesicular breath sounds in the peripheral lung fields
Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are normal findings. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults; therefore breath sounds are loud and harsh.
When inspecting the anterior chest of an adult, the nurse should include which assessment?
a. Diaphragmatic excursion
b. Symmetrical chest expansion
c. Presence of breath sounds
d. Shape and configuration of the chest wall.
d. Shape and configuration of the chest wall.
The nurse knows that auscultation of fine crackles would most likely be noticed in:
a. A healthy 5-year-old child.
b. A pregnant woman
c. The immediate newborn period
d. Association with a pneumothorax.
c. The immediate newborn period
Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid.
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
a. In an obese patient
b. When part of the lung is obstructed or collapsed.
c. when bulging of the intercostal spaces is present.
d. When accessory muscles are used to augment respiratory effect.
b. 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?
a. Airway obstruction
b. Emphysema
c. pulmonary consolidation
d. Asthma
c. pulmonary consolidation
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
a. Musical in quality
b. Usually caused by a pathological condition.
c. Expected near major airways.
d. Similar to bronchial sounds except shorter in duration.
c. Expected near 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?
a. Wheezes
b. Bronchial sounds
c. Bronchophony
d. Whispered pectoriloquy
a. Wheezes
A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?
a. Unequal chest expansion
b. Increased tactile fremitus
c. Atrophied neck and trapezius muscles
d. Anteroposterior-to-transverse diameter ratio of 1:1
d. Anteroposterior-to-transverse diameter ratio of 1:1
An anteroposterior-to-transverse diameter ratio of 1:1, or barrel chest, is observed in individuals with COPD because of hyperinflation of the lungs.
A 20-year-old tall, slim male patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyper-resonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:
a. Bronchitis
b. Pneumothorax
c. Acute pneumonia
d. Asthma attack
b. Pneumothorax
With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyper-resonant percussion tones, and decreased or absent breath sounds are found with the present of pneumothorax.
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:
a. Asthma
b. Atelectasis
c. Lobar pneumonia
d. Heart failure
a. Asthma
Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma.
The nurse is assessing the lungs of an 85-year-old patient who states having a decreased tolerance for activity. The nurse informs the patient that his results are some of the normal changes that occur in the respiratory system of the older adult:
a. Chest expansion increases with asymmetry
b. Respiratory muscles strength increases to compensate for decreased vital capacity
c. A decrease in small airway closure occurs, leading to problems with atelectasis
d. Lungs are less elastic and distensible, and this decreases their ability to collapse and recoil.
d. Lungs are less elastic and distensible, and this decreases their ability to collapse and recoil.
In older adults, the respiratory system is less efficient, and so they have less tolerance for activity. In aging adults the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing less surface area for gas exchange.
A woman in her 26th week of pregnancy states that she is “not really short of breath” but feels that she is aware of her breathing and the need to breathe. What is the nurse’s best reply?
a. “the diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.”
b. “The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.”
c. “What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal findings and nothing is wrong.”
d. “this increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mothers body, which results in an increased respiratory rate.
c. “What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal findings and nothing is wrong.”
During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong.
A 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 nurse’s preliminary analysis, based on this history, is that this patient may be suffering from:
a. Bronchitis
b. Pneumonia
c. Tuberculosis
d. Pulmonary edema
c. Tuberculosis
The appearance of sputum alone are not diagnostic, but some conditions have characteristic of sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers.
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?
a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema.
b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis.
c. Productive cough, dyspnea, weight-loss, anorexia, and tuberculosis.
d. Fever, dry nonproductive cough, and diminished breath sounds.
a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema.
A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, indicate tuberculosis; fever, dry nonproductive cough, and diminished break sounds may indicate pneumocystis jiroveci.
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.
a. Pneumonia
b. Postnasal drip
c. Exposure to irritants at work.
d. Chronic bronchial irritation from smoking.
b. Postnasal drip
A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses, such as pneumonia, is continuous throughout the day.
During a morning assessment, the nurse notices that the patient’s sputum is frothy and pink. Which condition could this finding indicate?
a. Croup
b. Tuberculosis
c. Viral infection
d. Pulmonary edema
d. Pulmonary edema
The appearance of sputum alone, is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic medications. Croup is associated with a barking cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections produce white or clear mucoid sputum.
To correctly auscultate the patient’s breath sounds, the nurse will:
a. Listen to at least one full respiration in each location.
b. Listen as the patient inhales and then go to the next site during exhalation.
c. Instruct the patient to breathe in and out rapidly while listening to the breath sounds.
d. If the patient is modest, listen to sounds over his or her clothing or hospital gown.
a. Listen to at least one full respiration in each location.
During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.
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?
a. Absent or decreased breath sounds
b. Productive cough with thin, frothy sputum
c. Chest pain that is worse on deep inspiration and dyspnea
d. diffuse infiltrates with areas of dullness upon percussion
c. Chest pain that is worse on deep inspiration and dyspnea
Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes.
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:
a. Tactile fremitus
b. Crepitus
c. friction rub.
d. Adventitious sounds.
b. Crepitus
Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, such as after open thoracic injury or surgery.
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 nurses recognizes that these breath sounds are:
a. Atelectatic crackles, which do not have a pathological cause.
b. Fine crackles and may be a sign of pneumonia.
c. Vesicular breath sounds
d. Fine wheezes.
a. Atelectatic crackles, which do not have a pathological cause.
One type of adventitious sound, atelectatic crackles, does not have a pathological cause. They are short, popping, crackling sounds that sound similar to find crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these secretions are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breath or after a cough.
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. Bradypnea
b. Cheyne-Stokes respirations
c. Hypoventilation
d. Chronic obstructive breathing
c. Hypoventilation.
Hypoventilation is characterized by an irregular, shallow pattern and and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute.
A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. Upon auscultation, the nurse notes coarse, low-pitched sounds with a grating quality and documents them as:
a. Stridor
b. Friction rub
c. Crackles
d. Wheezing
b. Friction rub
A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. This sound is superficial, coarse, and low pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases. Wheezes are associated with diffuse airway obstruction caused by acute asthma and chronic emphysema.
