Nursing 121 Final || with Error-free Solutions.
Subjective data for the respiratory system correct answers These include any diseases that they
patient has or has had in the past. These diseases can be chronic or acute. It can include any
recent health changes like pain, breathing patterns, edema, and wounds. Any treatments that the
patient has started like medications and surgeries are subjective data.The other things that are
included in subjective respiratory data are the same as with any other system: family history (any
risk factors and chronic illnesses that occur often in the family), culture (the environment the
client lives in, and any racial variations that may result in problems, because some races are more
likely to develop some things than other races), lifestyle (if you use tobacco, alcohol, or other
drugs, and what your diet and exercise habits are like), and health practices that you partake in
(annual screenings, hygiene, and stress management).
Family history and culture that affect gas transport system correct answers If there is any history
of cancer in the family involving the respiratory system? This includes cancer of the mouth,
throat, sinuses, lungs, and nose. Is there a history of lung disease or pulmonary disorders like
asthma or COPD? Did people in the house you grew up in smoke, and did they smoke around
you? Is there a history of diabetes, hypertension, coronary artery disease, or elevated cholesterol?
Objective data for the respiratory system correct answers Any data that you collect in your
physical assessment of the patient is considered objective data. When doing the assessment to
find the objective data, there are four things you should do, and they are in this order: inspection,
palpation, percussion, and ascultation. We should know to percuss, but we will not be required to
do this during our competency testing.
Things to look for in the head assessment of a respiratory system assessment correct answers The
main things you need to look at are the face, mouth, nose, and neck. When observing the mouth
you must look at the lips to see if they are nice and pink, or some other color like blue, and you
need to look in the oral cavity. If the lips are blue and discolored, it is likely that the patient has
poor circulation, and not enough oxygen rich blood is being distributed throughout the body. The
oral cavity, just as the lips, should be pink, and it should be moist with no ulcers or lacerations.
Take note of the state of their teeth, if they are healthy looking, is they are missing, and if they
are fake (dentures, or plates). When looking at the nose you need to look both inside and out.
Look at the outside to see if everything is symmetrical, if you can see any drainage, and if it is
red. You must also look for nasal flaring, or the nares flapping in and out as a person breathes.
This signals that a person is having a hard time breathing. Look inside the nose to see if the
passageway is clear or if there are any obstructions. Obstructions may include something that
was inserted into the nose, a deviated septum, or a polyp. Lastly, you want to look at the neck
and observe the jugular veins. If these veins can be seen pulsing, and if they are distended, this
could signal a heart problem, which will lead to respiratory problems. If there is JVD (jugular
vein distension) this means there is likely right sided heart failure. The distension means that
there is excess fluid that is being build up (edema) and pulmonary edema will also result, making
it a lot harder for the alveoli to expand and fill with air.
Carotid artery palpation correct answers You need to palpate these separately. Every pulse you
palpate, you are actually occluding the artery, which decreases blood flow to whatever area they
, lead to, and you don't want to block the blood flow to the head. The pulses should be the same on
both sides, if they are not, it can signal arterial constriction or occlusion. A weak pulse indicates
hypovolemia, shock, and a decreased cardiac output. A bounding pulse, or a pulse that is too
strong, indicates hypervolemia, and an increased cardiac output. If there is decreased elasticity of
the arteries, meaning they feel more hardened, it is a sign of atherosclerosis.
Crepitus correct answers This is a condition that is found, typically with subcutaneous
emphysema, but may also be found after chest surgery and when tubes are placed around the
thoracic cavity. It feels like a crackling sensation when you palpate the posterior thorax. If you
palpate for this condition, it means that air is escaping the patient's lungs and entering into the
subcutaneous tissue.
Posterior thorax palpation correct answers When you are palpating the posterior thorax, you are
palpating to find tenderness and sensation that the patient may feel, crepitus, masses and lesions,
fremitus, and chest expansion.
Fremitus correct answers This is one of the things that you palpate for when palpating the
posterior thorax. Fremitus presents with vibrations of air in the bronchial tubes transmitted to the
chest wall. Basically, it feels like the thoracic cavity is vibrating while you are palpating it. When
palpating for this, you follow the same pathway you follow while palpating for any other illness
affecting the thorax (start at midline level of left scapula, and then move to the right). As you
palpate, you should ask the patient to say "99", and you may feel vibrations. You are trying to
feel if the vibrations are symmetric, as well as how intense the vibrations are. It is normal for the
fremitus to decrease in strength as you get closer to the bases of the lungs. If fremitus is unequal
on both sides, this indicates bronchial obstruction, pneumothorax, trapped air, consolidation, and
pleural effusion.
Chest expansion correct answers This is another thing you are testing for during palpation of the
posterior thorax. At the T9-T10 vertebrae level, you should pinch a small skin fold together and
have the patient breathe deeply. You should observe how far apart your thumbs move, and if
they move an equal distance. If the thumbs collapse or move an unequal distance, this signals a
collapsed lung, pneumothorax, pneumonia, or a chest trauma. If there is decreased expansion at
the base of the lungs, this signals COPD due to decreased diaphragmatic function.
Percussing for tone on the posterior thorax correct answers You should begin percussing at the
apexes of the scapula, and then across the tops of the shoulders, then the intercostal spaces and
continue your way down. You should compare the sounds heard on both sides to each other. You
should hear resonance when you are on normal tissue, and a flat non-resonating sound when you
are persussing the scapula.
High pitched and dull sounds when percussing the thoracic cavity correct answers High pitched
sounds are typically produced when air is trapped in the lungs, like with emphysema and
pneumothorax. The high pitched sounds are also referred to as hyperresonance. A dull sound
means that there is fluid in the lung space. This can be caused by pneumonia, tumors, or a pleural
effusion (build up of fluid between the tissue and the pleural lining, it can place pressure on the
lungs).
Subjective data for the respiratory system correct answers These include any diseases that they
patient has or has had in the past. These diseases can be chronic or acute. It can include any
recent health changes like pain, breathing patterns, edema, and wounds. Any treatments that the
patient has started like medications and surgeries are subjective data.The other things that are
included in subjective respiratory data are the same as with any other system: family history (any
risk factors and chronic illnesses that occur often in the family), culture (the environment the
client lives in, and any racial variations that may result in problems, because some races are more
likely to develop some things than other races), lifestyle (if you use tobacco, alcohol, or other
drugs, and what your diet and exercise habits are like), and health practices that you partake in
(annual screenings, hygiene, and stress management).
Family history and culture that affect gas transport system correct answers If there is any history
of cancer in the family involving the respiratory system? This includes cancer of the mouth,
throat, sinuses, lungs, and nose. Is there a history of lung disease or pulmonary disorders like
asthma or COPD? Did people in the house you grew up in smoke, and did they smoke around
you? Is there a history of diabetes, hypertension, coronary artery disease, or elevated cholesterol?
Objective data for the respiratory system correct answers Any data that you collect in your
physical assessment of the patient is considered objective data. When doing the assessment to
find the objective data, there are four things you should do, and they are in this order: inspection,
palpation, percussion, and ascultation. We should know to percuss, but we will not be required to
do this during our competency testing.
Things to look for in the head assessment of a respiratory system assessment correct answers The
main things you need to look at are the face, mouth, nose, and neck. When observing the mouth
you must look at the lips to see if they are nice and pink, or some other color like blue, and you
need to look in the oral cavity. If the lips are blue and discolored, it is likely that the patient has
poor circulation, and not enough oxygen rich blood is being distributed throughout the body. The
oral cavity, just as the lips, should be pink, and it should be moist with no ulcers or lacerations.
Take note of the state of their teeth, if they are healthy looking, is they are missing, and if they
are fake (dentures, or plates). When looking at the nose you need to look both inside and out.
Look at the outside to see if everything is symmetrical, if you can see any drainage, and if it is
red. You must also look for nasal flaring, or the nares flapping in and out as a person breathes.
This signals that a person is having a hard time breathing. Look inside the nose to see if the
passageway is clear or if there are any obstructions. Obstructions may include something that
was inserted into the nose, a deviated septum, or a polyp. Lastly, you want to look at the neck
and observe the jugular veins. If these veins can be seen pulsing, and if they are distended, this
could signal a heart problem, which will lead to respiratory problems. If there is JVD (jugular
vein distension) this means there is likely right sided heart failure. The distension means that
there is excess fluid that is being build up (edema) and pulmonary edema will also result, making
it a lot harder for the alveoli to expand and fill with air.
Carotid artery palpation correct answers You need to palpate these separately. Every pulse you
palpate, you are actually occluding the artery, which decreases blood flow to whatever area they
, lead to, and you don't want to block the blood flow to the head. The pulses should be the same on
both sides, if they are not, it can signal arterial constriction or occlusion. A weak pulse indicates
hypovolemia, shock, and a decreased cardiac output. A bounding pulse, or a pulse that is too
strong, indicates hypervolemia, and an increased cardiac output. If there is decreased elasticity of
the arteries, meaning they feel more hardened, it is a sign of atherosclerosis.
Crepitus correct answers This is a condition that is found, typically with subcutaneous
emphysema, but may also be found after chest surgery and when tubes are placed around the
thoracic cavity. It feels like a crackling sensation when you palpate the posterior thorax. If you
palpate for this condition, it means that air is escaping the patient's lungs and entering into the
subcutaneous tissue.
Posterior thorax palpation correct answers When you are palpating the posterior thorax, you are
palpating to find tenderness and sensation that the patient may feel, crepitus, masses and lesions,
fremitus, and chest expansion.
Fremitus correct answers This is one of the things that you palpate for when palpating the
posterior thorax. Fremitus presents with vibrations of air in the bronchial tubes transmitted to the
chest wall. Basically, it feels like the thoracic cavity is vibrating while you are palpating it. When
palpating for this, you follow the same pathway you follow while palpating for any other illness
affecting the thorax (start at midline level of left scapula, and then move to the right). As you
palpate, you should ask the patient to say "99", and you may feel vibrations. You are trying to
feel if the vibrations are symmetric, as well as how intense the vibrations are. It is normal for the
fremitus to decrease in strength as you get closer to the bases of the lungs. If fremitus is unequal
on both sides, this indicates bronchial obstruction, pneumothorax, trapped air, consolidation, and
pleural effusion.
Chest expansion correct answers This is another thing you are testing for during palpation of the
posterior thorax. At the T9-T10 vertebrae level, you should pinch a small skin fold together and
have the patient breathe deeply. You should observe how far apart your thumbs move, and if
they move an equal distance. If the thumbs collapse or move an unequal distance, this signals a
collapsed lung, pneumothorax, pneumonia, or a chest trauma. If there is decreased expansion at
the base of the lungs, this signals COPD due to decreased diaphragmatic function.
Percussing for tone on the posterior thorax correct answers You should begin percussing at the
apexes of the scapula, and then across the tops of the shoulders, then the intercostal spaces and
continue your way down. You should compare the sounds heard on both sides to each other. You
should hear resonance when you are on normal tissue, and a flat non-resonating sound when you
are persussing the scapula.
High pitched and dull sounds when percussing the thoracic cavity correct answers High pitched
sounds are typically produced when air is trapped in the lungs, like with emphysema and
pneumothorax. The high pitched sounds are also referred to as hyperresonance. A dull sound
means that there is fluid in the lung space. This can be caused by pneumonia, tumors, or a pleural
effusion (build up of fluid between the tissue and the pleural lining, it can place pressure on the
lungs).
