NSG 214: Chapter 19: Thorax and Lungs Questions With
Complete Solutions
Increased tactile fremitus would be evident in an individual
who has which of the following conditions?
Crepitus
Emphysema
Pneumothorax
Pneumonia
Pneumonia
(Fremitus is a palpable vibration. Increased fremitus occurs with
compression or consolidation of lung tissue (e.g., lobar
pneumonia). Decreased fremitus occurs when anything obstructs
transmission of vibrations (e.g., obstructed bronchus, pleural
effusion or thickening, pneumothorax, or emphysema). 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. Decreased fremitus
occurs when anything obstructs transmission of vibrations (e.g.,
obstructed bronchus, pleural effusion or thickening,
pneumothorax, or emphysema).
Which of the following is a clinical manifestation in a patient
with chronic obstructive pulmonary disease (COPD)?
Periodic breathing patterns
Prolonged expiration
,Unequal chest expansion
Hyperventilation
Prolonged expiration
(A person with chronic obstructive lung disease commonly
experiences normal inspiration but prolonged expiration to
overcome the increased airway resistance. Periodic breathing
patterns are Cheyne-Stokes or Biot respirations. Cheyne-Stokes
respirations occur in heart failure, renal failure, meningitis, drug
overdose, and increased intracranial pressure; this type also
normally occurs in infants and older adults during sleep. Biot
respirations occur with head trauma, brain abscess, heat stroke,
spinal meningitis, and encephalitis. Unequal chest expansion
occurs when part of the lung is obstructed or collapsed, as with
pneumonia, or with guarding to avoid postoperative incisional
pain or pleurisy pain. Hyperventilation is a normal response to
fever, fear, or exercise; respiration rate also increases with
respiratory insufficiency, pneumonia, alkalosis, pleurisy, and
lesions in the pons.)
When auscultating lung sounds, it is important for the nurse
to do which of the following?
Anterior auscultation should include 9 spots on each side.
Quickly move through the assessment to decrease risk for
fainting or hyperventilation.
Tell the patient to stop the assessment if he/she begins to feel
dizzy.
, Complete assessment of right lung fields then move to
auscultate the left lung fields.
Tell the patient to stop the assessment if he/she begins to feel
dizzy.
(It’s important to instruct the patient to let you know if they are
beginning to feel dizzy during auscultation assessment as this is
an early sign of hyperventilating. Must listen to full inspiration
and expiration cycle and do not move quickly through the
assessment as this will lead to dizziness, hyperventilation, and
could cause the patient to faint. Lung sounds must be compared
in each spot between both lungs. Listening to all fields in one
lung prevents comparison. Anterior auscultation includes 5 spots
on each side. Posterior auscultation includes 9 spots on each
side.)
Inspiration is primarily facilitated by which of the following
muscles?
Internal intercostal and abdominis
Diaphragm and intercostal
Trapezius and sternomastoids
Diaphragm and rectus abdominis
Diaphragm and intercostal
(The major muscle responsible for inspiration is the diaphragm.
Intercostal muscles lift the sternum and elevate the ribs, making
them more horizontal; this increases the anteroposterior
diameter.)
Complete Solutions
Increased tactile fremitus would be evident in an individual
who has which of the following conditions?
Crepitus
Emphysema
Pneumothorax
Pneumonia
Pneumonia
(Fremitus is a palpable vibration. Increased fremitus occurs with
compression or consolidation of lung tissue (e.g., lobar
pneumonia). Decreased fremitus occurs when anything obstructs
transmission of vibrations (e.g., obstructed bronchus, pleural
effusion or thickening, pneumothorax, or emphysema). 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. Decreased fremitus
occurs when anything obstructs transmission of vibrations (e.g.,
obstructed bronchus, pleural effusion or thickening,
pneumothorax, or emphysema).
Which of the following is a clinical manifestation in a patient
with chronic obstructive pulmonary disease (COPD)?
Periodic breathing patterns
Prolonged expiration
,Unequal chest expansion
Hyperventilation
Prolonged expiration
(A person with chronic obstructive lung disease commonly
experiences normal inspiration but prolonged expiration to
overcome the increased airway resistance. Periodic breathing
patterns are Cheyne-Stokes or Biot respirations. Cheyne-Stokes
respirations occur in heart failure, renal failure, meningitis, drug
overdose, and increased intracranial pressure; this type also
normally occurs in infants and older adults during sleep. Biot
respirations occur with head trauma, brain abscess, heat stroke,
spinal meningitis, and encephalitis. Unequal chest expansion
occurs when part of the lung is obstructed or collapsed, as with
pneumonia, or with guarding to avoid postoperative incisional
pain or pleurisy pain. Hyperventilation is a normal response to
fever, fear, or exercise; respiration rate also increases with
respiratory insufficiency, pneumonia, alkalosis, pleurisy, and
lesions in the pons.)
When auscultating lung sounds, it is important for the nurse
to do which of the following?
Anterior auscultation should include 9 spots on each side.
Quickly move through the assessment to decrease risk for
fainting or hyperventilation.
Tell the patient to stop the assessment if he/she begins to feel
dizzy.
, Complete assessment of right lung fields then move to
auscultate the left lung fields.
Tell the patient to stop the assessment if he/she begins to feel
dizzy.
(It’s important to instruct the patient to let you know if they are
beginning to feel dizzy during auscultation assessment as this is
an early sign of hyperventilating. Must listen to full inspiration
and expiration cycle and do not move quickly through the
assessment as this will lead to dizziness, hyperventilation, and
could cause the patient to faint. Lung sounds must be compared
in each spot between both lungs. Listening to all fields in one
lung prevents comparison. Anterior auscultation includes 5 spots
on each side. Posterior auscultation includes 9 spots on each
side.)
Inspiration is primarily facilitated by which of the following
muscles?
Internal intercostal and abdominis
Diaphragm and intercostal
Trapezius and sternomastoids
Diaphragm and rectus abdominis
Diaphragm and intercostal
(The major muscle responsible for inspiration is the diaphragm.
Intercostal muscles lift the sternum and elevate the ribs, making
them more horizontal; this increases the anteroposterior
diameter.)
