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Questions and Answers
Which of these statements is true regarding the vertebra prominens?
Which of these statements is true regarding the vertebra prominens?
When performing respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
When performing respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:
When assessing a patient's lungs, the nurse recalls that the left lung:
When assessing a patient's lungs, the nurse recalls that the left lung:
Which statement about apices of the lungs is true?
Which statement about apices of the lungs is true?
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During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
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During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
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The primary muscles of respiration include the:
The primary muscles of respiration include the:
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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 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?
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When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
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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?
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?
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During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
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The correct method to use when progressing from one auscultatory site on the thorax to another is __________ comparison.
The correct method to use when progressing from one auscultatory site on the thorax to another is __________ comparison.
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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:
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:
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The nurse auscultating the chest in an adult. Which technique is correct?
The nurse auscultating the chest in an adult. Which technique is correct?
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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:
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:
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During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
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The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
The nurse knows that a normal finding when assessing the respiratory system of an older adult is:
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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 nurse's next action should be to:
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 nurse's next action should be to:
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When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?
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When inspecting the anterior chest of an adult, the nurse should include which assessment?
When inspecting the anterior chest of an adult, the nurse should include which assessment?
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The nurse knows that auscultation of fine crackles would most likely be noticed in:
The nurse knows that auscultation of fine crackles would most likely be noticed in:
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During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
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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?
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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The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true?
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true?
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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?
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?
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A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?
A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?
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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 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:
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An adult patient with a history of allergies comes to the clinic complaining of difficulty breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
An adult patient with a history of allergies comes to the clinic complaining of difficulty breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
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The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?
The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?
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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?
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?
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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:
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:
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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 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?
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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 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:
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During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?
During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?
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During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?
During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?
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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 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?
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During 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:
During 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:
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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:
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:
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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?
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?
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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 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?
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The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.
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Study Notes
Vertebra Prominens
- The vertebra prominens refers to the spinous process of C7, which is easily palpable in most individuals.
Respiratory Assessment Findings
- A costal angle of approximately 90 degrees is a normal finding in a healthy adult.
- The left lung contains two lobes, while the right lung has three lobes.
- The trachea bifurcates at the sternal angle, distinguishing it as an important landmark.
Lung Characteristics
- The apices of the lungs are located 3 to 4 cm above the inner third of the clavicles and are at the level of the second rib anteriorly.
- Normal lung assessment findings include symmetric tactile fremitus and muffled voice sounds.
Muscles of Respiration
- The primary muscles responsible for respiration are the diaphragm and intercostals.
Shortness of Breath Assessment
- In older patients with heart failure, shortness of breath during sleep may indicate paroxysmal nocturnal dyspnea.
Tactile Fremitus
- Tactile fremitus is normally felt most intensely between the scapulae, indicating healthy lung function.
- It reflects vibrations produced by sounds from the larynx and should be assessed during a respiratory examination.
Percussion and Auscultation Techniques
- A dull percussion note suggests increased density of lung tissue, commonly found in conditions like pneumonia.
- When auscultating, it is essential to compare sounds side-to-side for accurate assessment.
- Normal lung sounds in the lower lobes are vesicular, with inspiration being longer than expiration.
Age-related Changes
- In older adults, the thorax tends to have decreased mobility, which can limit respiratory function.
Pediatric Assessment
- In children, bronchovesicular breath sounds may be heard in peripheral lung fields, which is a normal finding.
- Signs like nasal flaring and intercostal retractions in infants indicate respiratory distress and require prompt evaluation.
Pathological Conditions
- Findings such as frothy, pink sputum can indicate pulmonary edema.
- Symptoms of a pneumothorax may include tracheal deviation away from the affected side, hyporesonance, and diminished breath sounds.
Specific Conditions
- Chronic obstructive pulmonary disease (COPD) is characterized by an anteroposterior-to-transverse diameter ratio of 1:1, indicating a barrel chest.
- Asthma may present with wheezing, prolonged expiration, and use of accessory muscles.
Auscultation of Adventitious Sounds
- Fine crackles may be present in newborns and indicate no pathologic cause if they stop after a few breaths.
- A friction rub is expected in pleuritis, characterized by pain with breathing.
Respiratory Patterns
- Shallow, irregular breathing with a respiratory rate of 12 may indicate hypoventilation.
Voice Sounds Assessment
- Normal voice sounds are faint, muffled, or indistinct when whispering, indicating adequate lung function.
- Clear bronchophony, where the examiner hears distinct words, suggests pulmonary consolidation.
Emergency Situations
- In cases of pulmonary embolism, expect chest pain worsening with deep breaths, along with dyspnea.
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Description
Test your knowledge on thorax and lung anatomy with these flashcards based on Chapter 19 of Jarvis. This quiz covers essential concepts, including the vertebra prominens and techniques for respiratory assessment.
