NR 509 Chapter_18 Jarvis: Physical Examination and Health Assessment, 5th edition [Chapter 18: Thorax and Lungs TEST BANK Completed A] - $19.49   Add to cart

Exam (elaborations)

NR 509 Chapter_18 Jarvis: Physical Examination and Health Assessment, 5th edition [Chapter 18: Thorax and Lungs TEST BANK Completed A]

1. Which of the following is true regarding the vertebra prominens? The vertebra prominens is: 1. the spinous process of C7. 2. usually not palpable in most individuals. 3. opposite the interior border of the scapula. 4. located next to the manubrium of the sternum. 2. When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is: 1. seen in patients with kyphosis. 2. indicative of pectus excavatum. 3. a normal finding in a healthy adult. 4. an expected finding in a patient with a barrel chest. 3. When assessing a patient’s lungs, the nurse recalls that the left lung: 1. consists of two lobes. 2. is divided by the horizontal fissure. 3. consists primarily of an upper lobe on the posterior chest. 4. is shorter than the right lung because of the underlying stomach. General 4. Which statement about the apices of the lungs is true? The apices of the lungs: 1. are at the level of the second rib anteriorly. 2. extend 3 to 4 cm above the inner third of the clavicles. 3. are located at the sixth rib anteriorly and the eighth rib laterally. 4. rest on the diaphragm at the fifth intercostal space in the midclavicular line. General 5. During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the: 1. costal angle. 2. sternal angle. 3. xiphoid process. 4. suprasternal notch. 6. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: 1. adventitious sounds and limited chest expansion. 2. increased tactile fremitus and dull percussion tones. 3. muffled voice sounds and symmetrical tactile fremitus. 4. absent voice sounds and hyperresonant percussion tones. 7. The primary muscles of respiration include the: 1. diaphragm and intercostals. 2. sternomastoids and scaleni. 3. trapezius and rectus abdominis. 4. external obliques and pectoralis major. 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? 1. Obtain a detailed history of the patient’s allergies and history of asthma. 2. Tell the patient to sleep on his or her right side to facilitate ease of respirations. 3. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. 4. Assure the patient that this is normal and will probably resolve within the next week. 9. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? 1. Between the scapulae 2. Third intercostal space, MCL 3. Fifth intercostal space, MAL 4. Over the lower lobes, posterior side 10. The nurse is aware that tactile fremitus is produced by: 1. moisture in the alveoli. 2. air in the subcutaneous tissues. 3. sounds generated from the larynx. 4. blood flow through the pulmonary arteries. 11. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: 1. shallow breathing. 2. normal lung tissue. 3. decreased adipose tissue. 4. increased density of lung tissue. 12. The most important technique when progressing from one auscultatory site on the thorax to another is: 1. side-to-side comparison. 2. top-to-bottom comparison. 3. posterior-to-anterior comparison. 4. interspace-by-interspace comparison. 13. When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse knows that these are: 1. sounds normally auscultated over the trachea. 2. bronchial breath sounds and are normal in that location. 3. vesicular breath sounds and are normal in that location. 4. bronchovesicular breath sounds and are normal in that location. 14. When auscultating the chest in an adult, the nurse would: 1. instruct the patient to take deep, rapid breaths. 2. instruct the patient to breathe in and out through his or her nose. 3. use the diaphragm of the stethoscope held firmly against the chest. 4. use the bell of the stethoscope held lightly against the chest to avoid friction. 15. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: 1. dullness. 2. tympany. 3. resonance. 4. hyperresonance. 16. During auscultation of the lungs, the nurse knows that decreased breath sounds would most likely be heard: 1. when the bronchial tree is obstructed. 2. when adventitious sounds are present. 3. in conjunction with whispered pectoriloquy. 4. in conditions of consolidation, such as pneumonia. 17. The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse’s best action would be to: 1. notify the physician. 2. suspect a pneumothorax. 3. consider this a normal finding. 4. monitor the infant’s respiratory rate and rhythm. 18. The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: 1. increased thoracic expansion. 2. decreased mobility of the thorax. 3. a decreased anteroposterior diameter. 4. bronchovesicular breath sounds throughout the lungs. 19. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had had “a runny nose for a week.” When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse’s next action should be to: 1. assure the mother that these are normal symptoms of a cold. 2. recognize that these are serious signs and contact the physician. 3. recognize that these are symptoms of rachitic rosary and refer the infant within the week. 4. perform a complete cardiac assessment because these are probably signs of early heart failure. 20. When assessing the respiratory system of a 4-year-old child, which of the following findings would the nurse expect? 1. Crepitus palpated at the costochondral junctions 2. No diaphragmatic excursion as a result of a child’s decreased inspiratory volume 3. The presence of bronchovesicular breath sounds in the peripheral lung fields 4. An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest 21. When inspecting the anterior chest of an adult, the nurse should assess for: 1. diaphragmatic excursion. 2. symmetric chest expansion. 3. the presence of breath sounds. 4. the shape and configuration of the chest wall. 22. The nurse knows that auscultation of fine crackles would most likely be noted in which situation? 1. In a healthy 5-year-old child 2. In the pregnant patient 3. In the immediate newborn period 4. In association with a pneumothorax 23. The nurse has noted unequal chest expansion and recognizes that this occurs when: 1. the patient is obese. 2. part of the lung is obstructed or collapsed. 3. bulging of the intercostal spaces is present. 4. accessory muscles are used to augment respiratory effort. 24. The nurse knows that bronchophony heard upon auscultation is associated with: 1. pneumothorax. 2. hyperresonance. 3. pulmonary consolidation. 4. decreased breath sounds. 25. The nurse knows that bronchovesicular breath sounds are: 1. musical in quality. 2. usually pathological. 3. expected near the major airways. 4. similar to bronchial sounds except that they are shorter in duration. 26. Air passing through narrowed bronchioles would produce which of the following adventitious sounds? 1. Wheezes 2. Bronchial sounds 3. Bronchophony 4. Whispered pectoriloquy 27. A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe: 1. unequal chest expansion. 2. increased tactile fremitus. 3. atrophied neck and trapezius muscles. 4. an anteroposterior-to-transverse diameter ratio of 1:1. 28. A teenage patient comes to the emergency department with complaints of an inability to “breathe and a sharp pain in my left chest.” The assessment findings include the following: cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. This description is consistent with: 1. bronchitis. 2. a pneumothorax. 3. acute pneumonia. 4. an asthmatic attack. 29. 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 the following: tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. This description is consistent with: 1. asthma. 2. atelectasis. 3. lobar pneumonia. 4. congestive heart failure. 18-13 30. Which of the following describes normal changes in the respiratory system of the older adult? 1. Severe dyspnea is experienced on exertion resulting from changes in the lungs. 2. Respiratory muscle strength increases to compensate for a decreased vital capacity. 3. There is a decrease in small airway closure, leading to problems with atelectasis. 4. The lungs are less elastic and distensible, decreasing their ability to collapse and recoil. 31. A woman in her 26th week of pregnancy states that she is “not really short of breath” but feels that she is aware of her breathing and the need to breathe. What is the nurse’s best reply? 1. “The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.” 2. “The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.” 3. “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.” 4. “This is normal as the fetus grows because of the increased oxygen demand on the mother’s body and results in an increased respiratory rate.” 18-14 32. When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true? 1. The smallest chest volumes are found in Asians. 2. The largest chest volumes are found in whites. 3. Asians are most likely to contract tuberculosis. 4. Racial differences are of no significance when assessing the respiratory system. 33. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse’s preliminary analysis, based on this history, is that this patient may be suffering from: 1. bronchitis. 2. pneumonia. 3. tuberculosis. 4. pulmonary edema. 34. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of the following findings is the nurse most likely to observe in this situation? 1. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema 2. Rasping cough, thick mucoid sputum, wheezing 3. Productive cough, dyspnea, weight loss, anorexia 4. Fever, dry nonproductive cough, bronchial breath sounds 35. 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 may indicate: 1. pneumonia. 2. postnasal drip or sinusitis. 3. exposure to irritants at work. 4. chronic bronchial irritation from smoking. ANS: 2 A cough that occurs mainly at night may indicate postnasal drip or sinusitis DIF: Application REF: Page: 446 MSC: NCLEX: Physiological Integrity: Physiological Adaptation 36. During a morning assessment, the nurse notes that the patient’s sputum is frothy and pink. Which condition could this finding indicate? 1. Croup 2. Tuberculosis 3. Viral infection 4. Pulmonary edema 37. During auscultation of breath sounds, the nurse will use the stethoscope correctly, as follows: 1. Listen to at least one full respiration in each location. 2. Listen as the patient inhales and then go to the next site during exhalation. 3. Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. 4. If the patient is modest, listen to sounds over his or her clothing or hospital gown. 38. A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse recognizes which assessment findings related to this condition? 1. Absent or decreased breath sounds 2. Productive cough with thin, frothy sputum 3. Chest pain that is worse on deep inspiration, dyspnea 4. Diffuse infiltrates with areas of dullness upon percussion 39. During palpation of the anterior chest wall, the nurse notes a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: 1. tactile fremitus. 2. crepitus. 3. friction rub. 4. adventitious sounds. 40. The nurse is auscultating the lungs of a patient who had been sleeping and notes short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: 1. atalectatic crackles, and not pathologic. 2. fine crackles and they may be a sign of pneumonia. 3. vesicular breath sounds. 4. fine wheezes. The nurse is assessing voice sounds during a respiratory assessment. Match the assessment with the correct technique: 1. The normal response is faint, muffled, and almost inaudible when the patient says “one, two, three” in a very soft voice. 2. Ask the person to say “ninety-nine” repeatedly while auscultating the chest wall. Normally, a sound will be heard but the examiner will not be able to distinguish exactly what is being said. 3. Listen to the chest while the patient says a long “ee-ee-ee” sound; hearing a long “aaaaaa” sound may be noted over areas of consolidation. 1. B = Bronchophony 2. E = Egophony 3. W = Whispered pectoriloquy

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