Chapter 15 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 15

Question 1

Type: HOTSPOT

The client aspirated a pea during a meal. The healthcare provider noted that the pea was in the bronchus. Draw an arrow to the most likely site of the pea.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The right main bronchus is shorter, wider, and more vertical than the left bronchus; therefore, aspirated objects are more likely to enter the right lung.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.1: Identify the anatomy and physiology of the respiratory system.

Question 2

Type: MCSA

The nurse is examining a client who has been diagnosed with a fracture of one floating rib. Of the following ribs, which does the nurse suspect to be fractured?

1. 1

2. 5

3. 9

4. 12

Correct Answer: 4

Rationale 1: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.

Rationale 2: Anteriorly, the first seven pairs of ribs articulate directly to the sternum.

Rationale 3: The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7.

Rationale 4: The rib pairs of 11 and 12 are free floating and do not articulate anteriorly.

Global Rationale: The 12 pairs of ribs circle the body, form the lateral aspects of the thorax, and are attached to the vertebrae and sternum. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7, whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.1: Identify the anatomy and physiology of the respiratory system.

Question 3

Type: HOTSPOT

Draw an arrow that points to the right anterior axillary line (AAL).

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The anterior axillary line (AAL) is a line drawn parallel to the sternal line. There are right and left anterior axillary lines. The lines begin at the anterior fold of the axillae and descend along the anterior lateral aspects of the thoracic cage to the twelfth rib.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory system.

Question 4

Type: MCSA

The nurse wants to assess the apex of a clients right lung. Which of the following locations should the nurse place the stethoscope to assess this area on the client?

1. Intercostal space 6th rib near the sternum

2. Intercostal space 4th rib near the axillary line

3. Below the scapula

4. Near the right clavicle

Correct Answer: 4

Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle.

Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle.

Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle.

Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle.

Global Rationale: The apex of each lung is slightly superior to the inner third of the clavicle whereas the base of each lung rests on the diaphragm.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory system.

Question 5

Type: MCSA

During the respiratory assessment of a client the nurse wishes to locate the angle of Louis. This structure can be identified by using which of the following landmarks?

1. Clavicle

2. Sternum

3. First rib

4. Vertebral column

Correct Answer: 2

Rationale 1: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Rationale 2: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Rationale 3: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Rationale 4: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Global Rationale: The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.2: Distinguish landmarks that guide assessment of the respiratory system.

Question 6

Type: MCSA

While assessing the client, the nurse notes that the client has a moist cough. The nurse would include which of the following questions in the focused interview?

1. Have you been losing weight?

2. How long have you been sick?

3. Are you wheezing?

4. Are you coughing up any mucus or phlegm?

Correct Answer: 4

Rationale 1: At this point, the client should not be questioned about weight loss.

Rationale 2: The client may not necessarily be sick.

Rationale 3: The client should be questioned about the cough during the focused interview and not about wheezing.

Rationale 4: The nurse must determine if the cough is productive or nonproductive. A moist cough is often associated with lung infections. The color and odor of any mucus or phlegm (sputum) is associated with specific diseases or problems

Global Rationale: The nurse must determine if the cough is productive or nonproductive. A moist cough is often associated with lung infections. The color and odor of any mucus or phlegm (sputum) is associated with specific diseases or problems. At this point, the client should not be questioned about weight loss. The client may not necessarily be sick. The client should be questioned about the cough during the focused interview and not about wheezing.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.3: Develop questions to be used when completing the focused interview.

Question 7

Type: MCSA

The nurse is assessing the clients respiratory system. Which of the following methods will result in the most accurate assessment of the clients respiratory rate?

1. The nurse should place a hand on the clients chest to count respirations accurately.

2. The nurse should inform the client that the nurse is counting the clients respirations.

3. The nurse should count only the respirations that are audible.

4. The nurse should count the respirations in an unobtrusive manner without informing the client.

Correct Answer: 4

Rationale 1: Though laying a hand on the clients chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive move and might increase the clients level of anxiety, which may affect the respiratory rate.

Rationale 2: The nurse should not inform the client about this portion of the assessment.

Rationale 3: Not all clients have audible respiratory cycles, and this would not be an effective method for accuracy.

Rationale 4: If a client knows his respirations are being counted, it may alter the normal breathing pattern.

Global Rationale: If a client knows his respirations are being counted, it may alter the normal breathing pattern. Though laying a hand on the clients chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive move and might increase the clients level of anxiety, which may affect the respiratory rate. The nurse should not inform the client about this portion of the assessment. Not all clients have audible respiratory cycles, and this would not be an effective method for accuracy.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.4: Explain client preparation for assessment of the respiratory system.

Question 8

Type: SEQ

The nurse is preparing to assess the clients respiratory system. Rank in order according to how the nurse should proceed.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Auscultation

Choice 2. Inspection

Choice 3. Percussion

Choice 4. Client survey

Choice 5. Palpation

Correct Answer: 4,2,5,3,1

Rationale 1: The fifth step in physical assessment of the respiratory system is auscultation.

Rationale 2: The second step of respiratory assessment is inspection of the anterior and posterior thorax.

Rationale 3: The fourth step in physical assessment of the respiratory system is percussion of the anterior and posterior thorax.

Rationale 4: The first step in any physical assessment is the client survey.

Rationale 5: The third step in respiratory assessment is palpation of the structures of the anterior and posterior thorax.

Global Rationale: The physical assessment of the respiratory system follows an organized pattern. It begins with the client survey, then inspection of the anterior and posterior thorax. The assessment ends with palpation, percussion, and auscultation of the anterior thorax.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system.

Question 9

Type: HOTSPOT

Draw an arrow to the area where tracheal breath sounds can be auscultated.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Tracheal breath sounds are heard over the trachea when the client inhales and exhales. They are harsh and high-pitched.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system.

Question 10

Type: MCSA

The client was brought to the Emergency Department. The nurse administered a breathing treatment for the client earlier. The nurse is preparing the client for a procedure. The nurse notes that the client is breathing in a shallow manner and the clients hands are trembling. Which of the following actions will help decrease the clients level of anxiety?

1. The nurse should explain all procedures in a calm and reassuring voice.

2. Request the immediate presence of the healthcare provider.

3. Provide oxygen for the client.

4. Postpone the procedure.

Correct Answer: 1

Rationale 1: Clients experiencing anxiety may demonstrate trembling hands and a shallow breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign with nervousness. Even mild respiratory distress is frightening for the client and family. Proceeding in a calm and reassuring manner helps reduce the clients fear.

Rationale 2: At this time, there is no reason to request the presence of the healthcare provider.

Rationale 3: There is not enough information about the information to assume the client requires oxygen.

Rationale 4: The nurse does not need to postpone the procedure.

Global Rationale: Clients experiencing anxiety may demonstrate trembling hands and a shallow breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign with nervousness. Even mild respiratory distress is frightening for the client and family. Proceeding in a calm and reassuring manner helps reduce the clients fear. At this time, there is no reason to request the presence of the healthcare provider. There is not enough information about the information to assume the client requires oxygen. The nurse does not need to postpone the procedure.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system.

Question 11

Type: MCSA

The nursing instructor is observing a student nurse assess the clients respiratory system. The student demonstrates proper technique for auscultation when moving the stethoscope:

1. From base to apices of lungs.

2. First up one side of the thorax, then up the other.

3. First down one side of the thorax, then down the other.

4. From side to side.

Correct Answer: 4

Rationale 1: The usual movement is from apices to the bases.

Rationale 2: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment.

Rationale 3: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment.

Rationale 4: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment.

Global Rationale: Auscultation should follow the same pattern as for percussion, from side to side, because comparison of sounds is an important step in respiratory assessment. Auscultate through the entire respiratory cycle, inspiration and expiration. The student nurse should ask the client to breathe deeply through the mouth each time the stethoscope is placed on the chest. The usual movement is from apices to the bases.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.5: Describe the techniques required for assessment of the respiratory system.

Question 12

Type: MCMA

The nurse is preparing to auscultate a clients lungs. Which of the following breath sounds would be considered abnormal?

Standard Text: Select all that apply.

1. Crackles

2. Vesicular

3. Bronchovesicular

4. Wheezes

5. Bronchial

Correct Answer: 1,4

Rationale 1: Crackles. Crackles are adventitious, or abnormal, lung sounds produced by collapsed or fluid-filled alveoli.

Rationale 2: Vesicular. Vesicular sounds are normal and can be heard over the apices.

Rationale 3: Bronchovesicular. Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi.

Rationale 4: Wheezes. Wheezes are the result of blocked airflow as in asthma, infection, or due to a foreign body.

Rationale 5: Bronchial. Bronchial sounds are normal and can be heard to the right and left of the trachea over the bronchi.

Global Rationale: Crackles are adventitious, or abnormal, lung sounds produced by collapsed or fluid-filled alveoli. Vesicular sounds are normal and can be heard over the apices. Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi. Wheezes are the result of blocked airflow as in asthma, infection, or due to a foreign body. Bronchial sounds are normal and can be heard to the right and left of the trachea over the bronchi.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 13

Type: MCSA

The nurse is assessing the client. The nurse hears low-pitched, continuous respiratory sounds that have a snoring quality while auscultating the clients lungs. The nurse would correctly document these findings as which of the following?

1. Rales

2. Crackles

3. Rhonchi

4. Wheezes

Correct Answer: 3

Rationale 1: Rales are intermittent, non-musical brief sounds.

Rationale 2: Coarser and louder rales are referred to as crackles.

Rationale 3: There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Rhonchi are low-pitched and have a snoring quality.

Rationale 4: There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Wheezes are high-pitched with a shrill quality.

Global Rationale: There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Rhonchi are low-pitched and have a snoring quality, while wheezes are high-pitched with a shrill quality. Rales are intermittent, nonmusical, brief sounds. Coarser and louder rales are referred to as crackles.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment

Question 14

Type: MCMA

While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. Which of the following conditions may produce this finding?

Standard Text: Select all that apply.

1. Atelectasis

2. Chronic bronchitis

3. Lobar pneumonia

4. Pleural effusion

5. Congestive heart failure

Correct Answer: 1,3,4

Rationale 1: Atelectasis. Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the clients affected side.

Rationale 2: Chronic bronchitis. Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side.

Rationale 3: Lobar pneumonia. It is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the clients affected side.

Rationale 4: Pleural effusion. This condition refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the clients affected side.

Rationale 5: Congestive heart failure. This is when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side.

Global Rationale: Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the clients affected side. Chronic bronchitis results in chronic inflammation of the tracheobronchial tree, which leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. Lobar pneumonia is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the clients affected side. Pleural effusion refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the clients affected side. Congestive heart failure occurs when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment

Question 15

Type: MCMA

The nurse is assessing a client with a severe left pleural effusion. Which of the following findings are expected?

Standard Text: Select all that apply.

1. Absent breath sounds on the left side

2. Tracheal shift to the right

3. Hyperresonance upon percussion.

4. Bronchial breath sounds of the right side

5. Pleural friction rub auscultated.

Correct Answer: 1,2,5

Rationale 1: Absent breath sounds on the left side. In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side.

Rationale 2: Tracheal shift to the right. In this condition, fluid accumulates in the pleural space. The trachea may shift to the unaffected side.

Rationale 3: Hyperresonance upon percussion. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion.

Rationale 4: Bronchial breath sounds of the right side. This is not a typical finding in someone who has been diagnosed with a pleural effusion.

Rationale 5: Pleural friction rub auscultated. In this condition, fluid accumulates in the pleural space, and a pleural friction rub may be present during auscultation.

Global Rationale: In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side, a tracheal shift to the unaffected side, and a pleural friction rub. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion. Bronchial breath sounds of the right side is not a typical finding in someone who has been diagnosed with a pleural effusion.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 16

Type: MCSA

The nurse is assessing the clients respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which of the following terms would the nurse use to document this finding?

1. Tachypnea

2. Obstructive breathing

3. Hypoventilation

4. Cheyne-Stokes

Correct Answer: 4

Rationale 1: The client who has tachypnea exhibits rapid and shallow respirations.

Rationale 2: Clients with obstructive breathing have prolonged expirations.

Rationale 3: Hypoventilation is irregular and shallow breathing.

Rationale 4: The breathing described is a Cheyne-Stokes pattern.

Global Rationale: The breathing described is a Cheyne-Stokes pattern. The client who has tachypnea exhibits rapid and shallow respirations. Clients with obstructive breathing have prolonged expirations. Hypoventilation is irregular and shallow breathing.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 17

Type: MCSA

During the assessment of a clients voice sounds, the nurse hears louder sounds over the clients right lower lobe. This finding would be consistent with:

1. Atelectasis.

2. Lobar pneumonia.

3. Asthma.

4. Pleural effusion.

Correct Answer: 2

Rationale 1: Voice sounds are decreased or absent over areas of atelectasis.

Rationale 2: Voice sounds are increased and clearer over areas affected by lobar pneumonia.

Rationale 3: Voice sounds are decreased or absent over areas of asthma.

Rationale 4: Voice sounds are decreased or absent over areas of pleural effusion.

Global Rationale: Voice sounds are decreased or absent over areas of atelectasis, asthma, pleural effusion, and pneumothorax. Voice sounds are increased and clearer over areas affected by lobar pneumonia.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 18

Type: MCSA

The nurse percusses the lungs and determines that there is an area of hyperresonance. This finding is consistent with which of the following conditions?

1. Pneumonia

2. Atelectasis

3. Pneumothorax

4. Pleural effusion

Correct Answer: 3

Rationale 1: When percussing a client with pneumonia the nurse would hear dullness over the affected area.

Rationale 2: When percussing a client with atelectasis the nurse would hear dullness over the affected area.

Rationale 3: Hyperresonance can be auscultated in clients with conditions that involve overinflated lungs such as emphysema and with pneumothorax.

Rationale 4: When percussing a client with a pleural effusion, the nurse would hear dullness over the affected area.

Global Rationale: Hyperresonance can be auscultated in clients with conditions that involve overinflated lungs such as emphysema and with pneumothorax. When percussing a client with pneumonia, atelectasis, or a pleural effusion, the nurse would hear dullness over the affected area.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 19

Type: MCSA

While the client sleeps, the nurse notes that the clients respirations periodically stop. This finding would be documented as:

1. Tachypnea.

2. Bradypnea.

3. Apnea.

4. Atelectasis.

Correct Answer: 3

Rationale 1: Tachypnea is a term used to describe rapid, shallow respirations that are greater than 24 per minute.

Rationale 2: Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute.

Rationale 3: Apnea is the cessation of breathing lasting from a few seconds to a few minutes.

Rationale 4: The findings do not indicate atelectasis, which is alveolar or lung collapse.

Global Rationale: Apnea is the cessation of breathing lasting from a few seconds to a few minutes. Tachypnea is a term used to describe rapid, shallow respirations that are greater than 24 per minute. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. The findings do not indicate atelectasis, which is alveolar or lung collapse.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 20

Type: MCSA

The nurse documents that the clients respirations are shallow and rapid. The clients respiratory rate is 30 per minute. From this finding, the nurse is concerned the client is:

1. Fatigued.

2. Anxious.

3. Normal.

4. Bored.

Correct Answer: 2

Rationale 1: Fatigue does not usually result in tachypnea.

Rationale 2: Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and may be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or pneumonia.

Rationale 3: Normal respirations are even and regular. A normal respiratory rate is over 10 and under 24 respirations per minute.

Rationale 4: The bored client may exhibit a slower respiratory rate.

Global Rationale: Tachypnea, or rapid, shallow respirations, are greater than 24 per minute and may be caused by fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, or pneumonia. Fatigue does not usually result in tachypnea. Normal respirations are even and regular. A normal respiratory rate is over 10 and under 24 respirations per minute. The bored client may exhibit a slower respiratory rate.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 21

Type: MCSA

During the assessment of a clients respiratory system, the nurse determines that the clients expiration phase is the same length as the inspiration phase. The clients respiratory rate is 14 per minute. The nurse would document this finding as:

1. obstructive breathing.

2. bradypnea.

3. respiratory distress.

4. normal.

Correct Answer: 4

Rationale 1: A client exhibiting obstructive breathing will have a prolonged expiration.

Rationale 2: Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute.

Rationale 3: These findings do not indicate that the client is experiencing respiratory distress.

Rationale 4: The finding describes eupnea, which is a normal breathing pattern.

Global Rationale: The finding describes eupnea, which is a normal breathing pattern. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. A client exhibiting obstructive breathing will have a prolonged expiration. These findings do not indicate that the client is experiencing respiratory distress.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 22

Type: MCSA

The nurse is preparing to assess an elderly client with emphysema. Which of the following anatomical changes would the nurse expect to find in this client?

1. Funnel chest

2. Barrel chest

3. Pigeon chest

4. Scoliosis

Correct Answer: 2

Rationale 1: Funnel chest is a congenital deformity characterized by depression of the sternum and adjacent costal cartilage.

Rationale 2: Clients with chronic obstructive pulmonary disease often have barrel chests. Aging can result in a barrel chest.

Rationale 3: Pigeon chest is a congenital deformity that is characterized by forward displacement of the sternum with depression of the adjacent costal cartilage.

Rationale 4: Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine.

Global Rationale: Clients with chronic obstructive pulmonary disease often have barrel chests. Aging can result in a barrel chest. Funnel chest is a congenital deformity characterized by depression of the sternum and adjacent costal cartilage. Pigeon chest is a congenital deformity that is characterized by forward displacement of the sternum with depression of the adjacent costal cartilage. Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 23

Type: MCSA

A client is demonstrating a diminished ability to exhale. The nurse realizes this client is at risk for developing:

1. Pleurisy.

2. Congestive heart failure.

3. Increased carbon dioxide levels.

4. Reduced oxygen capacity.

Correct Answer: 3

Rationale 1: Pleurisy results in pleuritic pain.

Rationale 2: This client is not at risk for developing congestive heart failure.

Rationale 3: During expiration, the carbon dioxide is expelled. Poor exhalation leads to retention of carbon dioxide.

Rationale 4: The clients oxygen capacity at this time is increased.

Global Rationale: During expiration, the carbon dioxide is expelled. Poor exhalation leads to retention of carbon dioxide. Pleurisy results in pleuritic pain. This client is not at risk for developing congestive heart failure. The clients oxygen capacity at this time is increased.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 24

Type: MCSA

A client with chronic bronchitis has been admitted to the hospital. The nurse inspects the client while assessing the clients respiratory system. Which of the following would be an expected finding?

1. Fever

2. Decreased respiratory rate

3. Use of accessory muscles

4. Dry cough

Correct Answer: 3

Rationale 1: The client will not typically experience a fever. Fevers are associated with infections.

Rationale 2: The respiratory rate may be elevated to compensate for the inability to breathe properly.

Rationale 3: Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways, causing decreased air movement in and out of the alveoli, which in turn causes the clients respiratory rate to increase in order to compensate. The muscles of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest wall expansion. The use of accessory muscles to breathe may be noted.

Rationale 4: This client will most likely exhibit a chronic productive cough.

Global Rationale: Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways, causing decreased air movement in and out of the alveoli, which in turn causes the clients respiratory rate to increase in order to compensate. The muscles of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest wall expansion. The use of accessory muscles to breathe may be noted. The client will not typically experience a fever. Fevers are associated with infections. The respiratory rate may be elevated to compensate for the inability to breathe properly. This client will most likely exhibit a chronic productive cough.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.6: Differentiate normal from abnormal findings in physical assessment.

Question 25

Type: MCSA

A 4-year-old childs respiratory rate is 30 per minute. The mother states, That seems like a really high number. My healthcare provider told me my respiratory rate is only 16 per minute. Which of the following is the nurses best response?

1. This is a normal finding for your childs age.

2. Your child is exhibiting a sign of a respiratory infection.

3. Your child requires further assessment.

4. Your child may simply be anxious.

Correct Answer: 1

Rationale 1: It is normal for children up to the age of 5 to have respiratory rates of up to 35 per minute.

Rationale 2: This child is not exhibiting a sign of a respiratory infection.

Rationale 3: This respiratory rate is normal for this childs age. The child does not require further assessment.

Rationale 4: This respiratory rate is normal for this childs age. The childs respiratory rate will increase with anxiety and the child may exhibit tachypnea.

Global Rationale: It is normal for children up to the age of 5 to have respiratory rates of up to 35 per minute. The other explanations are not appropriate for this situation. This child is not exhibiting a sign of a respiratory infection. This respiratory rate is normal for this childs age. The child does not require further assessment. The childs respiratory rate will increase with anxiety and the child may exhibit tachypnea.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 26

Type: MCSA

The client is 36 weeks pregnant. The nurse is assessing the clients respiratory system and finds that her respiratory rate is 24 breaths per minute. The client states that she sometimes experiences shortness of breath. Which of the following is the nurses best response?

1. You have developed asthma during your pregnancy.

2. During your last trimester, it is normal for you to feel short of breath and to have a faster respiratory rate.

3. Im going to have to notify your healthcare provider right now about these findings.

4. You have been infected with tuberculosis.

Correct Answer: 2

Rationale 1: The pregnant client has not developed asthma. Asthma is a chronic hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually occurs in response to inhaled irritants or allergens.

Rationale 2: Shortness of breath, dyspnea, and an increased respiratory are normal findings during the last trimester of pregnancy as the womans chest expands to accommodate the growing baby.

Rationale 3: These are normal findings for this pregnant client and the healthcare provider would not need to be notified.

Rationale 4: The client has not developed tuberculosis.

Global Rationale: Shortness of breath, dyspnea, and an increased respiratory are normal findings during the last trimester of pregnancy as the womans chest expands to accommodate the growing baby. The pregnant client has not developed asthma. Asthma is a chronic hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. Usually occurs in response to inhaled irritants or allergens. These are normal findings for this pregnant client and the healthcare provider would not need to be notified. The client has not developed tuberculosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 27

Type: MCSA

The nurse is percussing the anterior chest of an elderly client. Which of the following would the nurse expect to find in this client?

1. Flatness

2. Dullness

3. Tympany

4. Hyperresonance

Correct Answer: 4

Rationale 1: Percussion over bone will yield flat sounds.

Rationale 2: Percussion over solid organs or bones will yield a dull sound.

Rationale 3: Tympany is heard when percussion is performed over an air bubble.

Rationale 4: As a client ages, the function of the respiratory system becomes less efficient. The older adults lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest.

Global Rationale: As a client ages, the function of the respiratory system becomes less efficient. The older adults lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest. Percussion over bone will yield flat sounds. Tympany is heard when percussion is performed over an air bubble. Percussion over solid organs or bones will yield a dull sound.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 28

Type: MCSA

The nurse is caring for a teenager recently hospitalized with asthma. Several peers are preparing to visit the client and have brought gifts for the client. The nurse intervenes and prevents which of the following items from being brought into the patients room?

1. Magazines

2. Candy

3. MP3 player

4. Fresh flowers

Correct Answer: 4

Rationale 1: Magazines would be an appropriate gift for this client.

Rationale 2: Candy would be an appropriate gift for this client.

Rationale 3: An MP3 player would be an appropriate gift for this client.

Rationale 4: Limiting exposure to allergens, pollutants, and irritants in the clients environment is important to control and limit problems associated with respiratory health. Assessment must identify exposure to irritants such as dust, tobacco, smoke, pollen, smog, asbestos, and vapors from household cleaners. The clients friends should be prevented from bringing anything in the room that may expose the client to anything that is known to be a trigger for the condition.

Global Rationale: Limiting exposure to allergens, pollutants, and irritants in the clients environment is important to control and limit problems associated with respiratory health. Assessment must identify exposure to irritants such as dust, tobacco, smoke, pollen, smog, asbestos, and vapors from household cleaners. The clients friends should be prevented from bringing anything in the room that may expose the client to anything that is known to be a trigger for the condition. Objects void of any irritant would be the best selection for a gift. Magazines, candy, and an MP3 player would all be appropriate gifts for this client.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 29

Type: MCSA

As the nurse assesses the pregnant client she states that she sometimes feels like she has difficulty breathing. The client has reached the 36th week of her pregnancy. The nurse realizes that the clients difficulty is related to:

1. The fetus pushing the diaphragm upwards.

2. Fatigue due to the pregnancy.

3. Anxiety about her impending delivery.

4. Contractions.

Correct Answer: 1

Rationale 1: While the pregnant female is at rest, the diaphragm rises into the chest to accommodate the fetus. Shortness of breath and dyspnea, especially in the last trimester, are common as the maternal and fetal demand for oxygen increases.

Rationale 2: This feeling is not likely due to fatigue.

Rationale 3: This feeling is not likely due to anxiety.

Rationale 4: This feeling is not likely due to contractions.

Global Rationale: While the pregnant female is at rest, the diaphragm rises into the chest to accommodate the fetus. Shortness of breath and dyspnea, especially in the last trimester, are common as the maternal and fetal demand for oxygen increases. The remaining choices are not applicable for this situation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 30

Type: MCMA

The nurse is examining an African American client. When compared to Caucasians, which of the following conditions is this client at a higher risk for developing?

Standard Text: Select all that apply.

1. Asthma

2. Sarcoidosis

3. Tuberculosis

4. Obstructive sleep apnea

5. Chronic bronchitis

Correct Answer: 1,2,3,4

Rationale 1: Asthma. Asthma occurs more frequently in African Americans than in Caucasians.

Rationale 2: Sarcoidosis. Sarcoidosis occurs more frequently and with greater severity in African Americans than in Caucasians.

Rationale 3: Tuberculosis. Contracting tuberculosis is eight times more likely in African Americans than in Caucasians.

Rationale 4: Obstructive sleep apnea. Obstructive sleep apnea (OSA) is twice as likely to be experienced by young African Americans compared to young Caucasians.

Rationale 5: Chronic Bronchitis. African Americans are not necessarily more likely to develop chronic bronchitis.

Global Rationale: Asthma, sarcoidosis, TB, and obstructive sleep apnea occur more frequently in African Americans than in Caucasians. African Americans are not necessarily more likely to develop chronic bronchitis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 31

Type: MCMA

The nurse is preparing an educational program regarding Healthy People 2020. Which of the following pieces of information is important to include for caregivers of infants and young children?

Standard Text: Select all that apply.

1. Infants should always be placed to sleep on their backs.

2. Children should be taught to wash their hands.

3. Caregivers should ensure that the childrens toys are age-appropriate.

4. Parents should be educated about the importance of immunizations.

5. Caregivers should inspect the childrens toys for small possibly inhalable parts.

Correct Answer: 1,2,3,4,5

Rationale 1: Infants should always be placed to sleep on their backs. Infants who sleep on their backs have a reduced risk of developing sudden infant death syndrome (SIDS).

Rationale 2: Children should be taught to wash their hands. Children should be taught hygiene measures such as handwashing to prevent the spread of infection.

Rationale 3: Caregivers should ensure that the childrens toys are age-appropriate. Age-appropriate toys should be provided for children to ensure that young infants or children do not inhale small parts or choke on plastic bags that may found in toys meant to be played with by older children.

Rationale 4: Parents should be educated about the importance of immunizations. Children should be immunized to prevent the spread of preventable infections.

Rationale 5: Caregivers should inspect the childrens toys for small possibly inhalable parts. Some toys may include inhalable parts. Caregivers should ensure that they are providing toys that are safe.

Global Rationale: Infants who sleep on their backs have a reduced risk of developing sudden infant death syndrome (SIDS). Children should be taught hygiene measures such as handwashing to prevent the spread of infection. Age-appropriate toys should be provided for children to ensure that young infants or children do not inhale small parts or choke on plastic bags that may found in toys meant to be played with by older children. Children should be immunized to prevent the spread of preventable infections. Some toys may include inhalable parts. Caregivers should ensure that they are providing toys that are safe.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15.8: Discuss the objectives related to the overall health of the respiratory system as presented in Healthy People 2020.

Question 32

Type: MCSA

The nurse is assessing a 1-month-old infants respiratory system and sees that the infant is primarily using abdominal muscles to breathe and has an irregular breathing pattern. The nurse recognizes that this finding is:

1. A sign of severe respiratory distress.

2. An indicator that the infant has developed pneumonia.

3. A normal finding.

4. An indicator that the infant has developed a pneumothorax.

Correct Answer: 3

Rationale 1: Intercostal muscle retraction and prominent sternocleidomastoids may be seen in respiratory distress. This infant is not exhibiting any signs of respiratory distress.

Rationale 2: Infants are more susceptible to pneumonia than other populations, but this infant is not exhibiting any clinical manifestations of pneumonia.

Rationale 3: Abdominal breathing is the normal pattern for an infant and continues during childhood until ages 57, when the child develops costal breathing patterns. It is normal for an infant to exhibit an irregular breathing pattern.

Rationale 4: A pneumothorax is a condition in which air moves into the pleural space and causes partial or complete collapse of the lung. The client with a pneumothorax will exhibit tachypnea, decreased expansion of the chest wall on the affected side, and a tracheal shift to the unaffected side.

Global Rationale: Abdominal breathing is the normal pattern for an infant and continues during childhood until ages 57, when the child develops costal breathing patterns. It is normal for an infant to exhibit an irregular breathing pattern. Intercostal muscle retraction and prominent sternocleidomastoids may be seen in respiratory distress. This infant is not exhibiting any signs of respiratory distress. Infants are more susceptible to pneumonia than other populations, but this infant is not exhibiting any clinical manifestations of pneumonia. A pneumothorax is a condition in which air moves into the pleural space and causes partial or complete collapse of the lung. The client with a pneumothorax will exhibit tachypnea, decreased expansion of the chest wall on the affected side, and a tracheal shift to the unaffected side.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15.9: Apply critical thinking in selected simulations related to physical assessment of the respiratory system.

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