NURS 3320-600: Chapter 19: Thorax and Lungs Questions
With Complete Solutions
Pale or cyanotic
What is the appearance of nails with hypoxia?
Early clubbing
180 degree angle between nail and skin with spongy sensation
Late clubbing
inner edge of nail elevates; nail bed angle is greater than 180
degrees
With patient sitting with arms at sides, stand behind and observe
the position of the scapulae and shape and configuration of the
chest wall. Scapulae should be symmetric and non-protruding.
Shoulders and scapulae should have equal horizontal positions
Inspect the configuration of the thorax.
1:2
AP to transverse diameter ratio
Watch as the patient breathes and note use of accessory muscles.
Client should not use accessory muscles.
Observe use of accessory muscles.
Tripod positioning
, Client leans forward and uses arms to support weight and lift
chest to increase breathing capacity.
-Seen in COPD
Note posture and ability to support weight while breathing
comfortably. Patient is sitting up and relaxed, breathing easily
with arms at side or in lap.
Inspect the patient's positioning.
Use fingers to palpate for tenderness, warmth, pain, etc. Start
toward the midline at the level of the scapula (over the apex of
the left lung) and move your hands to the left and right,
comparing bilaterally. Move systematically downwards and out
to cover the lateral portions of the lungs at the bases. No
tenderness, pain, or sensations should be noted. Temperature
should be equal bilaterally.
Palpate for tenderness and sensation.
Crepitus
A crackling sensation that occurs when air passes through fluid
or exudate.
-palpated if air escapes from the lungs or other airways in sub q
tissue.
-palpated in extreme areas of congestion or consilidation
Use the ball of the hand to assess. Ask the patient to say 99 as
you move your hands around. Sound should vibrate
symmetrically and easily identified in the upper regions of the
lungs
Palpate for fremitus.
With Complete Solutions
Pale or cyanotic
What is the appearance of nails with hypoxia?
Early clubbing
180 degree angle between nail and skin with spongy sensation
Late clubbing
inner edge of nail elevates; nail bed angle is greater than 180
degrees
With patient sitting with arms at sides, stand behind and observe
the position of the scapulae and shape and configuration of the
chest wall. Scapulae should be symmetric and non-protruding.
Shoulders and scapulae should have equal horizontal positions
Inspect the configuration of the thorax.
1:2
AP to transverse diameter ratio
Watch as the patient breathes and note use of accessory muscles.
Client should not use accessory muscles.
Observe use of accessory muscles.
Tripod positioning
, Client leans forward and uses arms to support weight and lift
chest to increase breathing capacity.
-Seen in COPD
Note posture and ability to support weight while breathing
comfortably. Patient is sitting up and relaxed, breathing easily
with arms at side or in lap.
Inspect the patient's positioning.
Use fingers to palpate for tenderness, warmth, pain, etc. Start
toward the midline at the level of the scapula (over the apex of
the left lung) and move your hands to the left and right,
comparing bilaterally. Move systematically downwards and out
to cover the lateral portions of the lungs at the bases. No
tenderness, pain, or sensations should be noted. Temperature
should be equal bilaterally.
Palpate for tenderness and sensation.
Crepitus
A crackling sensation that occurs when air passes through fluid
or exudate.
-palpated if air escapes from the lungs or other airways in sub q
tissue.
-palpated in extreme areas of congestion or consilidation
Use the ball of the hand to assess. Ask the patient to say 99 as
you move your hands around. Sound should vibrate
symmetrically and easily identified in the upper regions of the
lungs
Palpate for fremitus.
