JARVIS Questions and answers, 2022 version, graded A+

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JARVIS Questions and answers, 2022 version, graded A+ Increased tactile fremitus would be evident in an individual who has which of the following conditions? - ✔✔Pneumonia Fremitus - ✔... ✔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 - ✔✔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. A common clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD) is: - ✔✔pursed-lip breathing. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse. 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. The thoracic cage comprises - ✔✔sternum, ribs, vertebrae, diaphragm. Inspiration is primarily facilitated by - ✔✔Diaphragm and intercostal muscles Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal; this increases the anteroposterior diameter. egophony: The "eeeee" sound is clear and sounds like "eeeee." - ✔✔normal bronchophony - ✔✔normal voice transmission is soft, muffled, and indistinct. whispered pectoriloquy - ✔✔normal, whispered sound is faint, muffled, and almost inaudible. The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of elderly adults cause: - ✔✔decreased surface area for gas exchange The function of the trachea and bronchi is to: - ✔✔transport gases between the environment and the lung parenchyma Stridor is a high-pitched, inspiratory crowing sound commonly associated with: - ✔✔upper airway obstruction. from swollen, inflamed tissues or a lodged foreign body. Percussion of the chest is: - ✔✔helpful only in identifying surface alterations of lung tissue. An abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Percussion detects only the outer 5 to 7 cm of tissue Percussion findings (resonant notes) may be modified by - ✔✔muscular chest wall of an athlete or subcutaneous tissue of an obese person. Resonance - ✔✔a low-pitched, clear, hollow sound that predominates with percussion of healthy lung tissue. lobes of the lungs and their anatomic position? - ✔✔The posterior chest is almost all lower lobe. The anterior chest contains mostly upper and middle lobe with very little lower lobe. An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n): - ✔✔increase in estrogen relaxes the chest cage ligaments. This allows an increase in the transverse diameter of the chest cage by 2 cm, and the costal angle widens central axillary lymph nodes - ✔✔Lying in the center of the axilla in the axillary fat, these nodes receive lymph from the lateral axillary, subscapular, and pectoral lymph nodes. subscapular lymph nodes - ✔✔along the lateral edge of the scapula, deep in the posterior axillary fold; these nodes receive superficial lymph vessels from the back, down as far as the level of the iliac crests. lateral axillary lymph nodes - ✔✔Lying along the medial side of the axillary vein, these nodes receive most of the lymph vessels of the upper limb pectoral lymph nodes - ✔✔along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold milk lines - ✔✔develop embryologic development. An embryonic ridge that extends between the limb buds of what will become the axillae and the inside of the pectoral region Tanner staging - ✔✔Sexual maturity rating used widely to assess and monitor the degree of maturation of an adolescent's primary and secondary sexual characteristics. thelarche - ✔✔beginning of breast development menarche - ✔✔the first menstrual period temporary asymmetry - ✔✔occasionally one breast may grow faster than other 2nd month - ✔✔time of pregnancy when breast changes occur colostrum - ✔✔a specialized form of milk that delivers essential nutrients and antibodies in a form that the newborn can digest 4th month - ✔✔colostrum can be potentially expressed after 4th month of pregnancy lactation - ✔✔production of milk; begins 1-e days postpartum emulsified fat, calcium caseinate - ✔✔gives milk it's white color prolactin - ✔✔stimulates milk production Cooper's ligaments - ✔✔suspensory ligaments; fibrous bands extending from the inner breast surface to the chest wall muscles Breast Quadrants - ✔✔4 quadrants of the surface of the breast for description of tumor and cysts Superior & Inferior lateral Superior & Inferior medial axillary tail of spence - ✔✔superior lateral corner of breast tissue that projects up and laterally into the axilla supraclavicular lymph node - ✔✔just above and behind the clavicle, at the sternomastoid muscle infraclavicular lymph node - ✔✔not strictly axillary nodes because they are located outside the axilla. They lie in the groove between the deltoid and pectoralis major muscles and receive superficial lymph vessels from the lateral side of the hand, forearm, and arm. parasternal lymph nodes - ✔✔Medial breast quadrant pass deeply to abdominal lymph nodes; Deep drainage along the internal thoracic vessels interpectoral lymph nodes (Rotter's lymph nodes) - ✔✔located between the pectoralis major and pectoralis minor muscles aging breasts - ✔✔Gland tissue atrophies; fat replaced with connective tissue; lose elasticity, droop, flatten; axillary hair decreases "Cooper's droopers" Males may experience gynecomastia; may be from testosterone deficiency; may be unilateral and temporary gynecomastia - ✔✔the condition of excessive mammary development in the male male breast - ✔✔Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple male breast cancer - ✔✔Most commonly seen after age 60 Tumors resemble carcinomas of the breast in women Crusting and nipple discharge are common clinical manifestations BRCA1 and BRCA2 - ✔✔genetic mutations associated with increased risk for breast cancer breast cancer - ✔✔a carcinoma that develops from the cells of the breast and can spread to adjacent lymph nodes and other body sites body image, society response, self-concept alterations - ✔✔cultural issues for breast cancer patients Montgomery glands - ✔✔sebaceous glands in the areola, secrete protective lipid during lactation; also called tubercles of Montgomery breast self-examination - ✔✔a self-care procedure for the early detection of breast cancer 4-7 - ✔✔For non-menopausal women, a breast self-exam should be performed ___________ to __________ days after cycle begins screening mammography - ✔✔-routine mammogram done even if the woman has no symptoms. Usually 2 views of each breast -baseline at age 40 -annually after age 45-54 -biennially after age 55 axilla - ✔✔underarm (armpit) Question for preadolescent girl - ✔✔Appearance: Have you noticed your breasts changing? Onset: How long has this been happening? Description: What have you noticed? Feelings: What do you think about all this? Sitting up facing examiner, supine - ✔✔A clinical exam should begin while the patient is ______________________ and continue while the patient is _________________. General appearance, skin color and condition, lymphatic drainage areas, nipple - ✔✔Things to assess during a clinical breast exam vertical strip method - ✔✔Place the finger pads of my middle three fingers against the top outer edge of the breast. Palpate downward, the upward working my way across the entire breast firm, smooth, and elastic - ✔✔breast tissue character in nulliparous women softer and looser - ✔✔breast tissue character after pregnancy location, size, shape, consistency, movable, distinctness, nipple, condition of skin over lump, tenderness, lymphadenopathy - ✔✔Breast exam items to screen for when a lump is detected oval, round, lobulated, indistinct - ✔✔potential breast lump shapes witch's milk - ✔✔Colostrum, formed under the influence of maternal hormones, which may be temporarily present in newborn's breasts. thoracic cage - ✔✔consists of thoracic vertebrae, the ribs and the sternum; protects the heart, lungs, thymus and other structures within the cavity; serves as an attachment site for muscles involved in respiration, positioning vertebral column, movements of the pectoral girdle and upper limb posterior thoracic cage - ✔✔landmarks include: -vertebra prominens: prominent bony spur (C7) -inferior border scapula: bottom of scapula -twelfth rib: midway between spine and side; floating rib anterior axillary line - ✔✔extends down from anterior axillary fold where pectoralis major muscle inserts midclavicular line - ✔✔imaginary vertical line bisecting the middle of the clavicle in each hemithorax vertebral line - ✔✔A line running vertically down through the spinous processes of the spine scapular line - ✔✔extends through the inferior angle of the scapula when the arms are at the sides of the body posterior axillary line - ✔✔a line that is parallel to the mid-axillary line and passes through the posterior axillary skinfold midaxillary line - ✔✔runs down from the apex of the axilla and lies between and parallel to the other two mediastinum - ✔✔area between the lungs containing the heart, aorta, venae cavae, esophagus, and trachea right and left pleural cavities - ✔✔on either side of the mediastinum, contain the lungs. right lung - ✔✔shorter of the two lungs left lung - ✔✔narrower of the two lungs 3 - ✔✔number of lobes of the right lung 2 - ✔✔number of lobes of the left lung pleurae - ✔✔serous membranes that form an envelope between the lungs and the chest wall visceral pleura - ✔✔inner layer of pleura lying closer to the lung tissue pleural cavity - ✔✔space between the folds of the pleura; a potential space with only a few milliliters of fluid pleural friction rub - ✔✔continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid pericardial friction rub - ✔✔described as grating, scratching sound of the heart indicative of pericarditis trachea - ✔✔a large membranous tube reinforced by rings of cartilage, extending from the larynx to the bronchial tubes and conveying air to and from the lungs; the windpipe. bronchi - ✔✔two short branches located at the lower end of the trachea that carry air into the lungs. right bronchus - ✔✔shorter, wiser, more vertical of first bronchi diaphragm - ✔✔Large, flat muscle at the bottom of the chest cavity that helps with breathing Accessory muscles of inspiration - ✔✔sternocleidomastoid and scalene muscles sternocleidomastoid, scalene muscles - ✔✔accessory muscles of inspiration lung cancer - ✔✔Second most common cancer worldwide. Leading cause is inhaled toxins (primarily smoking) tuberculosis - ✔✔An infectious disease that may affect almost all tissues of the body, especially the lungs asthma - ✔✔bronchial airway obstruction marked by paroxysmal dyspnea, wheezing, and cough; most chronic disease of childhood; highest burden seen in those living at or below the federal poverty level; ethnic and environmental factors play a significant role alveoli - ✔✔functional units of the lung; the thin-walled chambers surrounded by networks of capillaries that are the site of respiratory exchange of carbon dioxide and oxygen shortness of breath - ✔✔term used to indicate that a patient is having some difficulty breathing ask, advise, assess, assist, arrange - ✔✔5 A's of Smoking Cessation ___________ tactile fremitus - ✔✔a tremulous vibration of the chest wall during speaking that is palpable on physical examination symmetric chest expansion - ✔✔confirmed by placing warmed hands with thumbs @ t9 or t10 pinching small fold of skin - thumbs should move apart symmetrically lung fields - ✔✔-Symmetrical translucency Divide the lungs into upper middle and lower zones Compare side to side Do they look the same? -Lung markings should be Evenly spaced Extend all the way to the edges of the lung Percussion of lung fields - ✔✔should be tympanic (clear, hollow sound) on percussion Auscultation of lungs (posterior) - ✔✔auscultate the posterior thorax for sounds side to side. listen over bare skin to entire respiratory cycle of inspiration and expiration. bronchial sounds - ✔✔those heard over the trachea; high in pitch and intensity, with expiration being longer than inspiration bronchovesicular sounds - ✔✔Pertaining to the bronchial tubes and the alveoli with special reference to sounds intermediate between bronchial or tracheal sounds and alveolar sounds. vesicular sounds - ✔✔low-pitched, soft sounds heard over peripheral lung fields adventitous breath sounds - ✔✔abnormal breath sounds heard using a stethoscope with inspiration and/or expiration. these sounds can be continuous or discontinuous sounds crackles (rales) - ✔✔popping sounds heard on auscultation of the lung when air enters diseased airways and alveoli; occurs in disorders such as bronchiectasis or atelectasis fine crackles - ✔✔high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough course crackles - ✔✔series of long-duration, discontinuous, low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable brochial wall or fold of mucosa; evident on inspiration and, at times, expiration; similar sound to blowing through straw under water; increase in bubbling quality with more fluid wheeze (rhonchi) - ✔✔continuous musical sounds heard mainly over expiration atelectatic crackles - ✔✔sound like fine crackles but do not last and are not pathologic; disappear after the first few breaths voice sounds - ✔✔usually not done in routine exam. Test for presence of bronchophony, egophony, & whispered pectoriloquy bronchophony - ✔✔the spoken voice sound heard through the stethoscope, which sounds soft, muffled, and indistinct over normal lung tissue egophony - ✔✔abnormal change in tone of voice that is heard when auscultating the lungs whispered pectoriloquy - ✔✔a whispered phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissue Auscultation of lungs (anterior) - ✔✔ barrel chest - ✔✔a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema. Scoliosis (Lung impairment) - ✔✔Scoliosis > 90 Degree (pt will suffer form Dyspnea) Scoliosis >120 degree ( pt will suffer from significant hypo-ventilation and may have cor pulmonale Kyphosis lung impairment - ✔✔ pectus excavatum (funnel chest) - ✔✔most common congenital deformity of ant. wall of chest; several ribs & sternum grow abnormally; caved-in appearance; may impact lung capacity pectus carinatum (pigeon chest) - ✔✔sternum is protruding; comes to a point (limit amount of area the lungs can expand in the chest) sigh - ✔✔to breathe out slowly and noisily tachypnea - ✔✔rapid breathing hyperventilation - ✔✔the condition of taking abnormally fast, deep breaths bradypnea - ✔✔an abnormally slow rate of respiration usually of less than 10 breaths per minute hypoventilation - ✔✔deficient movement of air into and out of the lungs, causing hypercapnia cheyne-stokes respiration - ✔✔pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea Biot's respirations - ✔✔Rapid and deep respirations followed by 10 to 30 seconds of apnea chronic obstructive breathing - ✔✔normal inspiration and prolonged expiration to overcome increased airway resistance stridor - ✔✔Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages When performing respiratory assessment of an adult client the nurse notes hyperresonance on percussion. The nurse would conclude that this is due to which client condition? - ✔✔Pulmonary disease A client who has been diagnosed with a myocardial infraction presents with a complaint of "awakening in the middle of the night with a feeling of not being able to breathe". What is the appropriate action for the nurse to take? - ✔✔Instruct the client to sleep in semi-Fowler's position because of paroxysmal nocturnal dyspnea During a respiratory assessment, the nurse would elicit fremitus by doing which of the following during the examination? - ✔✔Placing the hands over anterior and posterior lung fields, asking the client to say "ninety-nine" The nurse is performing a respiratory assessment on a client who is presenting with an underlying obstructive respiratory disease. What is the most important question for the nurse to ask the client during the interview to provide information about contributing risk factors? - ✔✔" Have you ever smoked tobacco products?" The nurse has auscultated the client's lungs and hears bubbling sounds bilaterally in the lower lung fields. The nurse would document which finding in the client's medical record? - ✔✔Bilateral crackles at the bases The client is admitted to the hospital unit reporting inability to sleep because of shortness of breath. The nurse should take which preferred action? - ✔✔Have the client sleep on two pillows The nurse is performing a respiratory assessment on a client and finds unequal chest excursion. The nurse would conclude that this may be caused by which of the following factors? - ✔✔Collapse or obstruction of part of the lung The client has a history of chronic obstructive pulmonary disease (COPD). The nurse should expect to document which clinical manifestation following physical examination? Select all that apply - ✔✔Decreased bilateral excursion A transverse to anteroposterior diameter of 1:1 A client who has been in a motor vehicle accident (MVA) has decreased lung sounds on the right side of the chest, decreased fremitus, tracheal deviation to the left, and pain and hyperresonace on the left. The nurse should prepare to implement which nursing intervention? - ✔✔Prepare chest tube drainage setup In what order would the nurse complete the following components of a respiratory assessment on an assigned client? Place numbers that correspond to the options in correct sequence - ✔✔Explain the procedure to the client Position the client Palpate the anterior thorax Percuss the anterior thorax Auscultate the anterior thorax The nurse is caring for a client who has curvature of the thoracic and lumbar spine. The nurse should develop a plan of care based on which priority risk nursing diagnosis? - ✔✔Impaired gas exchange The client is admitted to the hospital. During the assessment the nurse notes dyspnea, decreased fremitus, dullness over the right lung, and decreased breath sounds on the right with a pleural friction rub. The nurse would prepare the client for diagnostic tests to evaluate the client for which health problem? - ✔✔Pleural effusion The nurse is assessing the client and notes shallow breathing with periods of apnea. When participating in interdisciplinary care rounds the nurse should report that the client is experiencing which of the following? - ✔✔Biot's breathing The nurse is caring for a client who is coughing up greenish-yellow mucus. Based on this clinical manifestations the nurse would conclude that the client is experiencing which respiratory condition? - ✔✔Lung infection The nurse is caring for an older adult client who states, " It is more difficult for me to breathe when I clean the house." To what would the nurse relate this clinical manifestation? - ✔✔A normal age-related change The nurse is teaching a client with allergies about work related allergens. To prevent respiratory distress the nurse should instruct the client to avoid which of the following? - ✔✔Contact with people who are smoking The nurse is assessing a client whose respiratory rate is 20 breaths per minute with symmetrical chest movement. The nurse will interpret this to be a normal finding in which client? - ✔✔Middle-aged client When assessing a client who reports a cough, it is essential that the nurse evaluate the cough by asking which of the following questions? Select all that apply - ✔✔" How long have you been coughing?" " Can you describe your cough?" " Are you coughing up mucus?" "Do you have pain when you cough?" The nurse is performing a respiratory assessment on an older adult client who has a history of dizziness and is at risk for falls. Which aspect of the respiratory assessment is most important for the nurse to complete in determining contributing factors that could enhance risk for falls? - ✔✔Respiratory rate to detect hyperventilation After percussing the client's thorax and hearing dullness in the right middle lobe, the nurse would conclude that this assessment finding is consistent with health problem? - ✔✔Tumor To thoroughly assess the chest and lungs: - ✔✔-It is important for the nurse to inspect and palpate the chest and to auscultate lung sounds. -Careful assessment of the chest and lungs helps the nurse to identify signs of respiratory conditions and is essential to the development of an effective treatment plan. During inspection of the chest, the nurse should observe the anterior and posterior thorax, noting thoracic landmarks for: - ✔✔-Size and shape (anteroposterior diameter compared with transverse diameter) -Color -Venous patterns -Symmetry during inhalation and exhalation -Superficial venous patterns -Prominence of ribs Thoracic landmarks are used to help identify the specific underlying structures affected during the physical examination: - ✔✔Midsternal line --Vertically down the midline of the sternum Right and left midclavicular lines --Parallel to the midsternal line --Begin at the midclavicle --Inferior borders of the lungs generally cross the sixth rib at the midclavicular line Right and left anterior axillary lines --Parallel to midsternal line --Beginning at anterior axillary folds Right and left midaxillary lines --Parallel to midsternal line --Beginning at the midaxilla Right and left posterior axillary lines --Parallel to midsternal line --Beginning at the posterior axillary folds Vertebral line --Vertically down the spinal processes Right and left scapular lines --Parallel to vertebral line --Through the inferior angle of the scapula when patient is erect Inspection of the Chest: Respiration... - ✔✔-During inspection, the nurse evaluates the patient's respirations for rate and rhythm by inspecting the chest wall. -Chest movement should be observed during breathing for symmetry and use of accessory muscles. -The nurse should also note any audible sounds with respiration. During inspection of the chest and lungs, the nurse should also observe other body areas for signs of respiratory compromise: - ✔✔-Cyanosis of lips and nails -Lip pursing -Nasal flaring -Clubbed nails (enlargement of the terminal phalanges of the fingers or toes) -Foul breath -Superficial venous patterns over the chest -Prominence of the ribs and underlying subcutaneous fat -Alae nasi During palpation of the chest, the nurse assesses for the following: - ✔✔-Chest symmetry and condition -Thoracic muscles and skeleton -Thoracic expansion -Pulsations -Tenderness -Bulges -Symmetry -Depressions -Masses -Unusual movement -Sensations (crepitus, grating vibrations, tactile fremitus) -Tracheal position/location Elements to Assess: Palpation for Tactile Fremitus... - ✔✔-To assess tactile fremitus, the nurse asks the patient to recite numbers or words. -While the patient does this, the nurse systematically palpates the chest with the palmar surfaces of fingers or the ulnar aspect of a clenched fist, using a firm, light touch. -The nurse assesses the area from front to back and side to side and then compares the sides. -Tactile fremitus can be best palpated posteriorly and laterally at the level of the bronchial bifurcation. Elements to Assess: Palpation of the Trachea... - ✔✔-Using the index finger and the thumb, the nurse gently palpates the neck from the suprasternal notch along the upper edges of each clavicle and in the spaces above the clavicles to the inner border of the sternocleidomastoid muscle. -Palpation of the trachea is often combined with assessment of the thyroid gland. This is discussed in more detail with the head and neck assessment. Elements to Assess: Anterior Chest Percussion... - ✔✔-The nurse percusses the anterior chest to estimate the location, size, and condition of underlying organs. -The nurse should ask the patient to sit with the head bent and arms raised overhead to percuss the lateral and anterior chest. -Moving superior to inferior and medial to lateral, the nurse percusses at 4- to 5-cm intervals over the intercostal spaces. -When assessing female patients, the nurse may need to shift the breast for accurate percussion, as breast tissue may obscure findings. -Areas to avoid during percussion of the chest include the scapula, spine, clavicles, and breast tissue. Elements to Assess: Posterior Chest Percussion... - ✔✔-To percuss the posterior chest, the nurse should have the patient lean forward with arms crossed and neck flexed. -Moving superior to inferior and medial to lateral, the nurse percusses at 4- to 5-cm intervals over the intercostal spaces. -Percussion tones over the chest should be compared bilaterally. Diaphragmatic excursion is the movement of the diaphragm during inhalation and exhalation. The steps to assess diaphragmatic excursion are as follows: - ✔✔A. Ask the patient to take a deep breath and hold it. B. Percuss along the scapular line until the lower border is found, when resonance turns to dullness. C. Mark the point with a marking pen at the scapular line. Allow patient to breathe, and then repeat procedure on the other side. D. Ask the patient to take several breaths and to exhale as much as possible, then hold his or her breath. E. Percuss up from the marked point and note where dullness changes to resonance. Remind the patient to start breathing. Repeat on the other side. F. Measure and record distance in centimeters between marks on each side. Auscultation of the patient's lungs is important to identify clues to lung condition... - ✔✔-During auscultation, the patient should sit upright, when possible, and should breathe slowly and deeply through the mouth, exaggerating normal respiration. -The nurse may need to demonstrate this breathing technique for the patient and should ensure the pace of breathing is comfortable for the patient. -The nurse asks the patient to take a deep breath each time the stethoscope is repositioned. -In addition to assessing lung sounds, this technique allows the nurse to assess the patient's ability to hear and follow commands. --The diaphragm of the stethoscope is preferable for lung auscultation. It is also best to auscultate directly against the skin, when possible. Auscultation through clothes can obscure findings. Elements to Assess: Auscultation of Chest and Lungs... - ✔✔-To properly auscultate the lungs, the nurse listens during both inhalation and exhalation, from superior to inferior and from apex toward base at intervals of several centimeters, comparing the two sides. -When a person is speaking, the voice transmits sounds through the lung fields that may be heard with the stethoscope. -The nurse auscultates vocal resonance by asking the patient to recite numbers or words when the stethoscope is against the patient's chest. -The nurse evaluates vocal resonance for the presence of bronchophony (increased loudness of spoken sounds), pectoriloquy (increased resonance, whisper heard clearly through the stethoscope), and egophony (increased intensity of spoken sounds with a nasal quality). -It is especially important to assess vocal resonance when abnormalities have been found during the percussion or tactile fremitus examination. Elements to Assess: Auscultation of Breath Sounds... - ✔✔During auscultation of the chest for breath sounds, it is important to assess the duration, vocal resonance, and presence of unexpected breath sounds. The pitch, intensity, quality, and duration should be noted. The expected breath sounds include the following: - ✔✔-Bronchial sounds (auscultate over the trachea) -Bronchovesicular sounds (auscultate over bronchi) -Vesicular sounds (auscultate over lung fields) Hyperresonance Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach. - ✔✔A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following? Hyperresonance Tympany Resonance Dullness Have the client cough, then listen again If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds would be done as part of any assessment of the thorax. - ✔✔Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? Chronic obstructive pulmonary disease (COPD) This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option. - ✔✔A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? "Please say the number 'ninety-nine' for me."; To palpate for fremitus, the nurse uses the ball or ulnar edge of one hand to assess for vibrations of air in the bronchial tubes transmitted to the chest wall. As the nurse moves a hand to each area, the client is asked to say "ninety-nine." None of the other listed actions will allow the nurse to assess for vibration in the chest wall. - ✔✔While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment? "When I say so, please exhale forcefully and hold the breath." "Say the letter 'e' and keep saying it until I tell you to stop." "Breathe in as deeply as you can and hold your breath until I say to stop." "Please say the number 'ninety-nine' for me."; Pulmonary embolism Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent). - ✔✔The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect? Listen at each site for at least one complete respiratory cycle The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds. - ✔✔Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields? Begin above the right clavicle and percuss each section comparing the right chest with the left chest. When percussing a patient's anterior chest, the nurse should begin above the level of the clavicles to assess the lung apex. The nurse should assess the right lung area and then the left. The nurse should proceed in a methodical manner and assess each lung area, comparing right to left. The nurse should not percuss all areas on the right side of the chest before assessing the left chest. The nurse should not percuss all areas on the left side of the chest before assessing the right chest. The nurse should not complete the assessment of the left chest and then reverse the process, assessing upward from the liver. - ✔✔The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment? Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological. - ✔✔When percussing the posterior lung fields, which of the following findings is expected? In the mediastinum : The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels. - ✔✔Question 4 See full question 12s A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body? The mediastinum - ✔✔what refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels. Patient C Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection. - ✔✔A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure [Show More]

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