Chapter 18: Thorax and Lungs My Nursing Test Banks

Chapter 18: Thorax and Lungs

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

a.

The spinous process of C7.

b.

Usually nonpalpable in most individuals.

c.

Opposite the interior border of the scapula.

d.

Located next to the manubrium of the sternum.

ANS: A

The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 414

MSC: Client Needs: General

2. When performing a respiratory assessment on a patient, the nurse notices 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.

ANS: C

The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 414

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

3. When assessing a patients lungs, the nurse recalls 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.

ANS: A

The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobes.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 415

MSC: Client Needs: General

4. Which statement about the apices of the lungs is true? The apices of the lungs:

a.

Are at the level of the second rib anteriorly.

b.

Extend 3 to 4 cm above the inner third of the clavicles.

c.

Are 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 (MCL).

ANS: B

The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 415

MSC: Client Needs: General

5. 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.

ANS: B

The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 416

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

6. 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 symmetric tactile fremitus.

d.

Absent voice sounds and hyperresonant percussion tones.

ANS: C

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.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 426 |p. 431

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

7. The primary muscles of respiration include the:

a.

Diaphragm and intercostals.

b.

Sternomastoids and scaleni.

c.

Trapezii and rectus abdominis.

d.

External obliques and pectoralis major.

ANS: A

The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck musclessternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 418

MSC: Client Needs: General

8. 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.

Obtaining a detailed health history of the patients allergies and a history of asthma

b.

Telling the patient to sleep on his or her right side to facilitate ease of respirations

c.

Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea

d.

Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

ANS: C

The patient is experiencing paroxysmal nocturnal dyspneabeing awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

DIF: Cognitive Level: Applying (Application) REF: p. 421

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

a.

Between the scapulae

b.

Third intercostal space, MCL

c.

Fifth intercostal space, midaxillary line (MAL)

d.

Over the lower lobes, posterior side

ANS: A

Normally, fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progresses down the chest because more tissue impedes sound transmission.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 426

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

10. 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.

ANS: C

Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 426

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

11. 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.

ANS: D

A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 427

MSC: Client Needs: General

12. 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

ANS: A

Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 435

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

13. 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:

a.

Normally auscultated over the trachea.

b.

Bronchial breath sounds and normal in that location.

c.

Vesicular breath sounds and normal in that location.

d.

Bronchovesicular breath sounds and normal in that location.

ANS: C

Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where air flows through smaller bronchioles and alveoli.

DIF: Cognitive Level: Applying (Application) REF: p. 430

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

14. The nurse is auscultating the chest in an adult. Which technique is correct?

a.

Instructing the patient to take deep, rapid breaths

b.

Instructing the patient to breathe in and out through his or her nose

c.

Firmly holding the diaphragm of the stethoscope against the chest

d.

Lightly holding the bell of the stethoscope against the chest to avoid friction

ANS: C

Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 429

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

15. 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.

Hyperresonance.

ANS: A

A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 427

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

16. 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 whispered pectoriloquy

d.

In conditions of consolidation, such as pneumonia

ANS: A

Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 430

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

17. The nurse knows that a normal finding 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.

ANS: B

The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 438

MSC: Client Needs: Health Promotion and Maintenance

18. 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 nurses 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.

ANS: B

The infant is an obligatory nose breather until the age of 3 months. Normally, no flaring of the nostrils and no sternal or intercostal retraction 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, immediate referral to the physician is warranted. These signs do not indicate heart failure, and an assessment of the infants feeding is not a priority at this time.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 437

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

19. When assessing the respiratory 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 childs 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

ANS: C

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.

DIF: Cognitive Level: Applying (Application) REF: p. 437

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

20. When inspecting the anterior chest of an adult, the nurse should include which assessment?

a.

Diaphragmatic excursion

b.

Symmetric chest expansion

c.

Presence of breath sounds

d.

Shape and configuration of the chest wall

ANS: D

Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patients level of consciousness and the patients skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 432

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

21. 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.

ANS: C

Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

DIF: Cognitive Level: Applying (Application) REF: p. 438

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

22. 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 effort

ANS: B

Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 432

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

23. 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

ANS: C

Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony (see Table 18-7).

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 449

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

24. 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 pathologic disease.

c.

Expected near the major airways.

d.

Similar to bronchial sounds except shorter in duration.

ANS: C

Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorlybetween the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 430

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

25. 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

ANS: A

Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 447

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

26. 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

ANS: D

An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

DIF: Cognitive Level: Applying (Application) REF: p. 448

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

27. A teenage 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, hyperresonance 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.

Asthmatic attack.

ANS: B

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, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. (See Table 18-8 for descriptions of the other conditions.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 454

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

28. 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.

ANS: A

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. (See Table 18-8 for descriptions of the other conditions.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 453

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

29. The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?

a.

Severe dyspnea is experienced on exertion, resulting from changes in the lungs.

b.

Respiratory muscle strength increases to compensate for a decreased vital capacity.

c.

Decrease in small airway closure occurs, leading to problems with atelectasis.

d.

Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

ANS: D

In the aging adult, 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. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 419

MSC: Client Needs: Health Promotion and Maintenance

30. 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 nurses 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 finding 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.

ANS: C

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. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mothers body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

DIF: Cognitive Level: Applying (Application) REF: p. 419

MSC: Client Needs: Health Promotion and Maintenance

31. 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 nurses preliminary analysis, based on this history, is that this patient may be suffering from:

a.

Bronchitis.

b.

Pneumonia.

c.

Tuberculosis.

d.

Pulmonary edema.

ANS: C

Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers (see Table 18-8).

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 455

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

32. 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

ANS: A

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, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia (see Table 18-8).

DIF: Cognitive Level: Applying (Application) REF: p. 448

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

33. 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 or sinusitis.

c.

Exposure to irritants at work.

d.

Chronic bronchial irritation from smoking.

ANS: B

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.

DIF: Cognitive Level: Applying (Application) REF: p. 420

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

34. During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate?

a.

Croup

b.

Tuberculosis

c.

Viral infection

d.

Pulmonary edema

ANS: D

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 may produce white or clear mucoid sputum.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 420

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

35. During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?

a.

Listening to at least one full respiration in each location

b.

Listening as the patient inhales and then going to the next site during exhalation

c.

Instructing the patient to breathe in and out rapidly while listening to the breath sounds

d.

If the patient is modest, listening to sounds over his or her clothing or hospital gown

ANS: A

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.

DIF: Cognitive Level: Applying (Application) REF: p. 429

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

36. 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

ANS: C

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.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 456

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

37. 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.

ANS: B

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.

DIF: Cognitive Level: Applying (Application) REF: p. 427

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

38. 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:

a.

Atelectatic crackles that do not have a pathologic cause.

b.

Fine crackles and may be a sign of pneumonia.

c.

Vesicular breath sounds.

d.

Fine wheezes.

ANS: A

One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to fine 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 sections 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 breaths or after a cough.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 431

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

39. 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

ANS: C

Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. (See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 444

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

40. 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?

a.

Stridor

b.

Friction rub

c.

Crackles

d.

Wheezing

ANS: B

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. The 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 (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

DIF: Cognitive Level: Applying (Application) REF: p. 449

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.

a.

Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice.

b.

As the patient repeatedly says ninety-nine, the examiner clearly hears the words ninety-nine.

c.

When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.

d.

As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound.

e.

As the patient says a long ee-ee-ee sound, the examiner hears a long aaaaaa sound.

ANS: A, C, D

As a patient repeatedly says ninety-nine, normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear ninety-nine is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says a long ee-ee-ee sound, normally the examiner also hears a long ee-ee-ee sound through auscultation, which is a measure of egophony. If the examiner hears a long aaaaaa sound instead, this sound could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as one-two-three, the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

DIF: Cognitive Level: Applying (Application) REF: p. 449

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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