TB-Chapter 19 Thorax and Lungs PDF

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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK

TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

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Chapter19:ThoraxandLungs MULTIPLECHOICE 1.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.

c.

Oppositetheinteriorborderofthescapula.

d.

Locatednexttothemanubriumofthesternum.

ANS:A ThespinousprocessofC7isthevertebraprominensandisthemostprominentbonyspurprotrudingatthe baseoftheneck.Countingribsandintercostalspacesontheposteriorthoraxisdifficultbecauseofthemuscle andsofttissue.Thevertebraprominensiseasiertoidentifyandisusedasastartingpointincountingthoracic processesandidentifyinglandmarksontheposteriorchest. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 2.Whenperformingarespiratoryassessmentonapatient,thenursenoticesacostalangleofapproximately90 NURSINGTB.COM 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.

ANS:C Therightandleftcostalmarginsformananglewheretheymeetatthexiphoidprocess.Usually,thisangleis 90degreesorless.Theangleincreaseswhentheribcageischronicallyoverinflated,asinemphysema. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 3.Whenassessingapatientslungs,thenurserecallsthattheleftlung: a.

Consistsoftwolobes.

b.

Isdividedbythehorizontalfissure.

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c.

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

d.

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

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ANS:A Theleftlunghastwolobes,andtherightlunghasthreelobes.Therightlungisshorterthantheleftlung becauseoftheunderlyingliver.Theleftlungisnarrowerthantherightlungbecausetheheartbulgestothe left.Theposteriorchestisalmostalllowerlobes. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 4.Whichstatementabouttheapicesofthelungsistrue?Theapicesofthelungs: a.

Areatthelevelofthesecondribanteriorly.

b.

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

c.

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). NURSINGTB.COM

ANS:B Theapexofthelungontheanteriorchestis3to4cmabovetheinnerthirdoftheclavicles.Ontheposterior chest,theapicesareatthelevelofC7. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 5.Duringanexaminationoftheanteriorthorax,thenurseisawarethatthetracheabifurcatesanteriorlyatthe: a.

Costalangle.

b.

Sternalangle.

c.

Xiphoidprocess.

d.

Suprasternalnotch.

ANS:B Thesternalanglemarksthesiteoftrachealbifurcationintotherightandleftmainbronchi;itcorrespondswith theupperbordersoftheatriaoftheheart,anditliesabovethefourththoracicvertebraontheback. DIF:CognitiveLevel:Remembering(Knowledge)

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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 6.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.

ANS:C Normallungfindingsincludesymmetricchestexpansion,resonantpercussiontones,vesicularbreathsounds overtheperipherallungfields,muffledvoicesounds,andnoadventitioussounds. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 7.Theprimarymusclesofrespirationincludethe: a.

Diaphragmandintercostals. NURSINGTB.COM

b.

Sternomastoidsandscaleni.

c.

Trapeziiandrectusabdominis.

d.

Externalobliquesandpectoralismajor.

ANS:A Themajormuscleofrespirationisthediaphragm.Theintercostalmusclesliftthesternumandelevatetheribs duringinspiration,increasingtheanteroposteriordiameter.Expirationisprimarilypassive.Forcedinspiration involvestheuseofothermuscles,suchastheaccessoryneckmusclessternomastoid,scaleni,andtrapezii muscles.Forcedexpirationinvolvestheabdominalmuscles. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 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? 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

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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

ANS:C Thepatientisexperiencingparoxysmalnocturnaldyspneabeingawakenedfromsleepwithshortnessofbreath andtheneedtobeuprighttoachievecomfort. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 9.Whenassessingtactilefremitus,thenurserecallsthatitisnormaltofeeltactilefremitusmostintenselyover whichlocation? a.

Betweenthescapulae

b.

Thirdintercostalspace,MCL

c.

Fifthintercostalspace,midaxillaryline(MAL)

d.

Overthelowerlobes,posteriorside NURSINGTB.COM

ANS:A Normally,fremitusismostprominentbetweenthescapulaeandaroundthesternum.Thesesitesarewherethe majorbronchiareclosesttothechestwall.Fremitusnormallydecreasesasoneprogressesdownthechest becausemoretissueimpedessoundtransmission. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 10.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.

ANS:C Fremitusisapalpablevibration.Soundsgeneratedfromthelarynxaretransmittedthroughpatentbronchiand thelungparenchymatothechestwallwheretheyarefeltasvibrations.Crepitusisthetermforairinthe

NURSINGTB.COM

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subcutaneoustissues. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 11.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.

ANS:D Adullpercussionnoteindicatesanabnormaldensityinthelungs,aswithpneumonia,pleuraleffusion, atelectasis,oratumor.Resonanceistheexpectedfindinginnormallungtissue. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:General NURSINGTB.COM 12.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

c.

Posterior-to-anterior

d.

Interspace-by-interspace

ANS:A Side-to-sidecomparisonismostimportantwhenauscultatingthechest.Thenurseshouldlistentoatleastone fullrespirationineachlocation.Theothertechniquesarenotcorrect. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 13.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.

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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.

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ANS:C Vesicularbreathsoundsarelow-pitched,softsoundswithinspirationbeinglongerthanexpiration.These breathsoundsareexpectedovertheperipherallungfieldswhereairflowsthroughsmallerbronchiolesand alveoli. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 14.Thenurseis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 NURSINGTB.COM

ANS:C Firmlyholdingthediaphragmofthestethoscopeagainstthechestisthecorrectwaytoauscultatebreath sounds.Thepatientshouldbeinstructedtobreathethroughhisorhermouth,alittledeeperthanusual,butnot tohyperventilate. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 15.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.

c.

Resonance.

d.

Hyperresonance.

ANS:A Adullpercussionnotesignalsanabnormaldensityinthelungs,aswithpneumonia,pleuraleffusion,

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atelectasis,oratumor. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 16.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

c.

Inconjunctionwithwhisperedpectoriloquy

d.

Inconditionsofconsolidation,suchaspneumonia

ANS:A Decreasedorabsentbreathsoundsoccurwhenthebronchialtreeisobstructed,asinemphysema,andwhen soundtransmissionisobstructed,asinpleurisy,pneumothorax,orpleuraleffusion. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 17.Thenurseknowsthatanormalfindingwhenassessingtherespiratorysystemofanolderadultis: NURSINGTB.COM

a.

Increasedthoracicexpansion.

b.

Decreasedmobilityofthethorax.

c.

Decreasedanteroposteriordiameter.

d.

Bronchovesicularbreathsoundsthroughoutthelungs.

ANS:B Thecostalcartilagesbecomecalcifiedwithaging,resultinginalessmobilethorax.Chestexpansionmaybe somewhatdecreased,andthechestcagecommonlyshowsanincreasedanteroposteriordiameter. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:HealthPromotionandMaintenance 18.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nasa flaringandsternalandintercostalretractions.Thenursesnextactionshouldbeto: a.

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

b.

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

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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.

ANS:B Theinfantisanobligatorynosebreatheruntiltheageof3months.Normally,noflaringofthenostrilsandno sternalorintercostalretractionoccurs.Significantretractionsofthesternumandintercostalmusclesandnasal flaringindicateincreasedinspiratoryeffort,asinpneumonia,acuteairwayobstruction,asthma,andatelectasis; therefore,immediatereferraltothephysicianiswarranted.Thesesignsdonotindicateheartfailure,andan assessmentoftheinfantsfeedingisnotapriorityatthistime. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 19.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

c.

Presenceofbronchovesicularbreathsoundsintheperipherallungfields NURSINGTB.COM

d.

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

ANS:C Bronchovesicularbreathsoundsintheperipherallungfieldsoftheinfantandyoungchilduptoage5or6 yearsarenormalfindings.Theirthinchestwallswithunderdevelopedmusculaturedonotdampenthesound, asdothethickerchestwallsofadults;therefore,breathsoundsareloudandharsh. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 20.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

ANS:D

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Inspectionoftheanteriorchestincludesshapeandconfigurationofthechestwall;assessmentofthepatients levelofconsciousnessandthepatientsskincolorandcondition;qualityofrespirations;presenceorabsenceof retractionandbulgingoftheintercostalspaces;anduseofaccessorymuscles.Symmetricchestexpansionis assessedbypalpation.Diaphragmaticexcursionisassessedbypercussionoftheposteriorchest.Breathsounds areassessedbyauscultation. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 21.Thenurseknowsthatauscultationoffinecrackleswouldmostlikelybenoticedin: a.

Ahealthy5-year-oldchild.

b.

Apregnantwoman.

c.

Theimmediatenewbornperiod.

d.

Associationwithapneumothorax.

ANS:C Finecracklesarecommonlyheardintheimmediatenewbornperiodasaresultoftheopeningoftheairways andaclearingoffluid.Persistentfinecrackleswouldbenoticedwithpneumonia,bronchiolitis,oratelectasis. DIF:CognitiveLevel:Applying(Application)

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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 22.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

c.

Whenbulgingoftheintercostalspacesispresent

d.

Whenaccessorymusclesareusedtoaugmentrespiratoryeffort

ANS:B Unequalchestexpansionoccurswhenpartofthelungisobstructedorcollapsed,aswithpneumonia,orwhen guardingtoavoidpostoperativeincisionalpain. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 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?

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a.

Airwayobstruction

b.

Emphysema

c.

Pulmonaryconsolidation

d.

Asthma

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ANS:C Pathologicconditionsthatincreaselungdensity,suchaspulmonaryconsolidation,willenhancethe transmissionofvoicesounds,suchasbronchophony. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 24.Thenurseisreviewingthecharacteristicsofbreathsounds.Whichstatementaboutbronchovesicularbre...