NURS 526 Exam 2 Review Advanced Assessment

NURS 526 Exam 2 Review Advanced Assessment Respiratory 1. What is tactile fremitus page ? 273 o The palpable vibration of the chest wall that results from speech or other verbalizations. Fremitus is best felt posteriorly and laterally at the level of bifurcation of the bronchi. There is great variability depending on the intensity and pitch of the voice and structure and thickness of the chest wall. (99 and Mickey Mouse are favorite words to have the patient say, while you systematically palpate both sides. Decreased or absent fremitus may be caused by excess air in the lungs or may indicate emphysema, pleural thickening or effusion, massive pulmonary edema, or bronchial obstruction. Increased fremitus , often coarser or rougher in feel, occurs in the presence of fluids or solid mass within the lungs and may be caused by lung consolidation, have but non obstructive bronchial secretions, compressed lung or tumor Gentle more tremulous fremitus than expected occurs with some lung consolidations and some inflammatory and infectious processes o Dullness to percussion and tactile fremitus are the most useful finding for pleural effusion. Dullness to chest percussion makes the probability of a pleural effusion more likely. The absence of reduced tactile vocal fremitus makes the pleural effusion less likely. Tactile fremitus is best felt a. along the costal margin and xiphoid process. b. in the suprasternal notch along the clavicle. c. at the level of bifurcation of the bronchi. d. posterolaterally over the scapulas. e. in the midaxillary lines. ANS: C Fremitus is best felt posteriorly and laterally at the level of the bifurcation of the bronchi. There is great variability depending on the intensity and pitch of the voice and the structure and thickness of the chest wall. In addition, the scapulae obscure fremitus. 2. What is resonance? page 274 o Auscultate for vocal resonance as the patient repeats numbers or words. They normally sound muffled and indistinct and are best heard medially. Listen for three types of altered resonance. (The generally lower pitched voices of men lend an intensity to vocal fremitus that is often greater than in women. The factors the influence tactile fremitus similarly influence vocal resonance. o Resonance is an expected sound that can usually be heard over all areas of the lungs during percussion o Hyperresonance is associated with hyperinflation and may indicate emphysema, pneumothorax, or asthma o Dullness or flatness suggests pneumonia, pleural effusion, pneumothorax or asthma Dullness to percussion in intercostal spaces is most consistent with the presence of a. asthma. b. empyema. c. pneumonia. d. sickle cell disease. e. pneumothorax. ANS: C The expected percussion tone over normal lung tissue, accessible in the intercostal spaces, is resonance. Dullness would indicate an area of consolidation, as is seen with pneumonia. Both pleural effusion and lobar pneumonia are characterized by percussion. a. tympany heard with b. dullness heard on c. resonance heard on d. hyperresonance heard on e. occasional hyperresonance heard on ANS: B Pleural effusion and lobar pneumonia are more dense than air, with an expected finding of dullness to percussion. Tympany is expected over hollow organs such as the stomach; resonance and hyperresonance are heard over air-filled areas. 3. What is broncophony page 279 o Greater clarity and increased loudness of spoken sounds is defined as broncophony. 4. What is pectoriloquy page 279 o If broncophony is extreme, (as in the presence of consolidation of the lungs) even a whisper can be heard clearly and intelligibly through the stethoscope. This is referred to as whispered pectoriloquy 5. What is egophony page 279 o When the intensity of spoken voice is increased and there is a nasal quality ( stuffy and broad) the auditory quality is called egophony During chest assessment, you note the patient’s voice quality while you are auscultating the lung fields. The voice sound is intensified, there is a nasal quality to the voice, and e’s sound like a’s. This sound described is called a. sonorous. b. bronchophony. c. pectoriloquy. d. egophony. e. resonance. ANS: D When the intensity of the spoken voice is increased, there is a nasal quality in which the e’s become stuffy broad a’s. This technique is called egophony. During chest assessment, you note the patient’s voice quality while auscultating the lung fields. The voice sound is intensified, there is a nasal quality to the voice, and the e’s sound like a’s. This is indicative of a. lung consolidation. b. emphysema. c. bronchial obstruction. d. pneumothorax. e. asthma. ANS: A Vocal resonance, as described, indicates lung consolidation. Sounds are transmitted more clearly through consolidation rather than air. Conditions of air trapping such as emphysema and asthma would not produce vocal resonance sounds; bronchial obstruction would more likely result in a wheeze. Pneumothorax would result in diminished or no breath sounds. 6. How do you differentiate between a respiratory friction rub and a cardiac friction rub? page 278 o A friction rub occur outside the respirator tree. It has a dry, crackly, grating, low pitched sound and is heard in both expiration and inspiration. It may have a machine like quality. It may have no significance if heard over the liver or spleen; however, a friction rub heard over the heart of lungs is caused by inflamed, roughened surfaces rubbing together. Over the pericardium, this sound suggest pericarditis; over the lungs, pleurisy. The respiratory rub disappears when the breath is held, the cardiac rub does not. To distinguish between a respiratory friction rub and a cardiac friction rub, ask the patient to a. hold his or her breath. b. lean forward. c. say “99” while you palpate the anterior chest. d. identify the location of his or her pain. e. arch backward. ANS: A A respiratory friction rub results from inflamed pleura rubbing against each other during the respiratory cycle, so if the breath is held, the rub stops. You would expect to document the presence of a pleural friction rub for a patient being treated for a. bronchitis. b. atelectasis. c. pleurisy. d. emphysema. e. pneumonia. ANS: C A pleural friction rub is caused by inflammation of the pleural surfaces and is expected to be auscultated with pleurisy. 7. How do you differentiate different lung sounds, i.e. crackles from rhonchi? Page 278 o A crackle is an abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinues sounds, each lasting just a few milliseconds. The individual noise tends to be brief and the interval to the next one similarly brief, crackles may be fine, high pitched, and relatively short in duration or coarse, low pitched and relatively longer in duration. They are caused by the disruptive passage of air through the small airways in the respiratory tree High pitched crackles are described as sibilant, the more low pitched crackles are termed sonorous. Crackles with a dry quality, more crisp than gurgling are apt to occur higher in the respiratory tree. You might listen for crackles at the open mouth. If their origin is in the upper airways, they will be easily heard; if in the lower, not so easily. o Rhonchi is a nonporous wheeze, deeper more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles.. They are caused by passage of air thorough an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure The more sibilant, higher pitched rhonchi arise from larger bronchi, as a in tracheobronchitis. All rhonchi may at times be palpable o It may be difficult to distinguish between crackles and rhonchi, in general, rhonchi tend to disappear after coughing, whereas crackles do not To distinguish crackles from rhonchi, you should auscultate the lungs a. before and after the patient coughs. b. first at the lung base and then at the apex. c. with the patient inhaling and then exhaling. d. with the patient prone and then supine. e. with the patient recumbent and then sitting. ANS: A To distinguish between crackles and rhonchi, ask the patient to cough and auscultate again over the same area. Rhonchi, because they represent secretions in larger airways, can clear with coughing.