Jarvis Chapter 19

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

a. The spinous process of C7.

b. Usually nonpalpable in most individuals

с. Opposite the interior border of the scapula.

d. Located next to the manubrium of the sternum.

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

a. The spinous process of C7.

b. Usually nonpalpable in most individuals

с. Opposite the interior border of the scapula.

d. Located next to the manubrium of the sternum.

A

When performing respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

a. Observed in patients with kyphosis. b. Indicative of pectus excavatum.

c. A normal finding in a healthy adult.

d. An expected finding in a patient with a barrel chest.

C

When assessing a patients lungs, the nurse recalls that the left lung:

a. Consists of two lobes.

b. Is divided by the horizontal fissure.

c. Primarily consists of an upper lobe on the posterior chest

d. Is shorter than the right lung because of underlying stomach.

A

Which statement about apices of the lungs is true? The apices of the lungs:

а. Are at the level of the second rib anteriorly

b. Extend 3 to 4 cm above the inner third of the clavicles.

с. Are located at the sixth rib anteriorly and the eighth rib laterally

d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

B

During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:

а. Costal angle

b. Sternal angle.

с. Xiphoid process.

d. Suprasternal notch.

B

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of

a. Adventitious sounds and limited chest expansion.

b. Increased tactile fremitus and dull percussion tones.

c. Muffled voice sounds and symmetric tactile fremitus.

d. Absent voice sounds and hyperresonant percussion tones.

C

The primary muscles of respiration include the:

a. Diaphragm and intercostals.

b. Sternomastoids and scaleni.

с. Trapezii and rectus abdominis.

d. External obliques and pectoralis major.

A

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?

a. Obtaining a detailed health history of the patients allergies and a history of asthma

b. Telling the patient to sleep on his or her right side to facilitate ease of respirations

c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea

d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week

C

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

а. Between the scapulae

b. Third intercostal space, MCL

с. Fifth intercostal space, midaxillary line (MAL)

d. Over the lower lobes, posterior side

A

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus:

a. Is caused by moisture in the alveoli. b. Indicates that air is present in the subcutaneous tissues.

c. Is caused by sounds generated from the larynx.

d. Reflects the blood flow through the pulmonary arteries.

C

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

a. Shallow breathing.

b. Normal lung tissue.

c. Decreased adipose tissue.

d. Increased density of lung tissue.

D

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ___________comparison.

a. Side-to-side

b. Top-to-bottom

с. Posterior-to-anterior

d. Interspace-by-interspace

A

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:

a. Normally auscultated over the trachea.

b. Bronchial breath sounds and normal in that location

c. Vesicular breath sounds and normal in that location

d. Bronchovesicular breath sounds and normal in that location.

C

The nurse auscultating the chest in an adult. Which technique is correct?

a. Instructing the patient to take deep, rapid breaths

b. Instructing the patient to breathe in and out through his or her nose

c. Firmly holding the diaphragm of the stethoscope against the chest

d. Lightly holding the bell of the stethoscope against the chest to avoid friction

C

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:

a. Dullness

b. Tympany.

с. Resonance.

d. Hyperresonance.

A

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

a. When the bronchial tree is obstructed

b. When adventitious sounds are present

с. In conjunction with whispered pectoriloquy

d. In conditions of consolidation, such as pneumonia

A

The nurse knows that a normal finding when assessing the respiratory system of an older adult is:

а. Increased thoracic expansion.

b. Decreased mobility of the thorax.

c. Decreased anteroposterior diameter. d. Bronchovesicular breath sounds throughout the lungs.

B

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has 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 nurses next action should be to:

а. Assure the mother that these signs are normal symptoms of a cold

b. Recognize that these are serious signs, and contact the physician.

c. Ask the mother if the infant has had trouble with feedings

d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

B

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

a. Crepitus palpated at the costochondral junctions

b. No diaphragmatic excursion as a result of a childs decreased inspiratory volume

с. Presence of bronchovesicular breath sounds in the peripheral lung fields

d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

C

When inspecting the anterior chest of an adult, the nurse should include which assessment?

a. Diaphragmatic excursion

b. Symmetric chest expansion

c. Presence of breath sounds

d. Shape and configuration of the chest wall

D

The nurse knows that auscultation of fine crackles would most likely be noticed in:

а. A healthy 5-year-old child.

b. A pregnant woman.

c. The immediate newborn period.

d. Association with a pneumothorax.

C

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

a. In an obese patient

b. When part of the lung is obstructed or collapsed

с. When bulging of the intercostal spaces is present

d. When accessory muscles are used to augment respiratory effort

B

23. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony, The nurse should assess for signs of which condition?

a. Airway obstruction

b. Emphysema

c. Pulmonary consolidation

d. Asthma

C

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

а. Musical in quality.

b. Usually caused by a pathologic disease.

с. Expected near the major airways.

d. Similar to bronchial sounds except shorter in duration.

C

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

а. Wheezes

b. Bronchial sounds

с. Bronchophony

d. Whispered pectoriloquy

A

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

а. Unequal chest expansion

b. Increased tactile fremitus

с. Atrophied neck and trapezius muscles

d. Anteroposterior-to-transverse diameter ratio of 1:1

D

27. A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

a. Bronchitis

b. Pneumothorax

с. Acute pneumonia.

d. Asthmatic attack.

B

An adult patient with a history of allergies comes to the clinic complaining breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck of wheezing and difficulty in muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

a. Asthma

b. Atelectasis.

c. Lobar pneumonia.

d. Heart failure.

A

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?

a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs.

b. Respiratory muscle strength increases to compensate for a decreased vital capacity

c. Decrease in small airway closure occurs, leading to problems with atelectasis.

d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

D

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 nurses best reply?

a. The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.

b. The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.

с. 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.

d. This increased awareness of the need to breathe normal as the fetus grows because of the increased oxygen demand on the mothers body, which results in an increased respiratory rate.

C

31. 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 nurses preliminary analysis, based on this history, is that this patient may be suffering from:

a. Bronchitis.

b. Pneumonia.

с. Tuberculosis.

d. Pulmonary edema.

C

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?

a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis

c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis

d. Fever, dry nonproductive cough, and diminished breath sounds

A

33. 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 cough may indicate:

a. Pneumonia.

b. Postnasal drip or sinusitis.

с. Exposure to irritants at work.

d. Chronic bronchial irritation from smoking.

B

During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate?

a. Croup

b. Tuberculosis

c. Viral infection

d. Pulmonary edema

D

During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?

a. Listening to at least one full respiration in each location

b. Listening as the patient inhales and then going to the next site during exhalation

с. Instructing the patient breathe in and out rapidly while listening to the breath sounds

d. If the patient is modest, listening to sounds over his or her clothing or hospital gown

A

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

a. Absent or decreased breath sounds

b. Productive cough with thin, frothy sputum

с. Chest pain that is worse on deep inspiration and dyspnea

d. Diffuse infiltrates with areas of dullness upon percussion

C

Durning palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

a. Tactile fremitus.

b. Crepitus.

с. Friction rub.

d. Adventitious sounds.

B

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

a. Atelectatic crackles that do not have a pathologic cause.

b. Fine crackles and may be a sign of pneumonia.

с. Vesicular breath sounds.

d. Fine wheezes.

A

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following?

а. Bradypnea

b. Cheyne-Stokes respirations

c. Hypoventilation

d. Chronic obstructive breathing

C

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?

a. Stridor

b. Friction rub

с. Crackles

d. Wheezing

B

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply

a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice.

b. As the patient repeatedly says ninety-nine, the examiner clearly hears the words ninety-nine.

с. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.

d. As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound.

e. As the patient says a long ee-ee-ee sound, the examiner hears a long aaaaaa sound.

A, C, D