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Chapter 19: Thorax and Lungs Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition MULTIPLE CHOICE
- The nurse is teaching the nursing students to palpate the vertebra prominens when beginning posterior thoracic assessment of a patient. The students will: a. Look for the spinous process of C7. b. Usually not be able to palpate this on most individuals. c. Find the interior border of the scapula. d. Locate this 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 muscles 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: Understanding (Comprehension) MSC: Client Needs: General
- When performing a respiratory assessment on a patient, the nurse notes 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. 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
- When assessing a patient’s lungs, the nurse recognizes 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 the underlying stomach. 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)
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MSC: Client Needs: General
- The nurse landmarks the apices of the lungs to: a. Be at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Be 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). 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: Understanding (Comprehension) MSC: Client Needs: General
- 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) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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 symmetrical tactile fremitus. d. Absent voice sounds and hyper-resonant percussion tones. ANS: C Normal lung findings include symmetrical 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
- The primary respiratory muscles engaged in normal inspiration include the: a. Diaphragm and intercostals. b. Sternomastoid and scalene. c. Trapezius and rectus abdominis.
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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
- 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 subcutaneous tissues. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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 tumour. Resonance is the expected finding in normal lung tissue. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
- 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.
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DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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 these sounds as: a. Normally auscultated over the trachea. b. Bronchial breath sounds, which are normal in that location. c. Vesicular breath sounds, which are normal in that location. d. Bronchovesicular breath sounds, which are normal in that location. 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
- The nurse is auscultating the chest of an adult patient. 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 patient’s skin d. Lightly holding the bell of the stethoscope over the gown to avoid friction ANS: C Firmly holding the diaphragm of the stethoscope against the skin of the chest is the correct way to auscultate breath sounds and decrease extraneous sounds from the gown. 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
- 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. Hyper-resonance. ANS: A A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumour. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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- 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 child’s decreased inspiratory volume c. 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 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
- When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetrical chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall ANS: D Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient’s level of consciousness and the patient’s skin colour and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetrical 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
- 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 observed with pneumonia, bronchiolitis, or atelectasis. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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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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
- 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 ANS: C Pathological conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony (see Table 19-3). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: a. Musical in quality. b. Usually caused by a pathological condition. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration. ANS: C Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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? a. Wheezes b. Bronchial sounds c. Bronchophony d. Whispered pectoriloquy ANS: A
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a. Asthma. b. Atelectasis. c. Lobar pneumonia. d. Heart failure. ANS: A Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. (See Table 19-8 for descriptions of the other conditions.) DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- The nurse is assessing the lungs of an 85-year-old patient who states having a decreased tolerance for activity. The nurse informs the patient that this results from some of the normal changes that occur in the respiratory system of the older adult: a. Chest expansion increases with asymmetry. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. c. A decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, and this decreases their ability to collapse and recoil. ANS: D In older adults, the respiratory system is less efficient (decreased vital capacity, less surface area for gas exchange), and so they have less tolerance for activity. In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance
- 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. “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.” c. “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 is normal as the fetus grows because of the increased oxygen demand on the mother’s body, which results in an increased respiratory rate.” ANS: C
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During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother’s body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance
- A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-coloured 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. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema. ANS: C The appearance of sputum alone are not diagnostic, but some conditions have characteristic sputum production. Tuberculosis often produces rust-coloured sputum in addition to other symptoms of night sweats and low-grade afternoon fevers (see Table 19-8). DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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 ANS: A A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci ( P. carinii ) pneumonia (see Table 19-8). DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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. c. Exposure to irritants at work.
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ANS: C
Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO 2 ) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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: a. Tactile fremitus. b. Crepitus. c. Friction rub. d. Adventitious sounds. ANS: B 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, such as after open thoracic injury or surgery. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
- 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, which do not have a pathological cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes. ANS: A One type of adventitious sound, atelectatic crackles, does not have a pathological cause. They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing
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ANS: C
Hypoventilation is characterized by an irregular, shallow pattern and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. (See Table 19-5 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.) DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. Upon auscultation, the nurse notes coarse, low-pitched sounds with a grating quality and documents them as: a. Stridor. b. Friction rub. c. Crackles. d. Wheezing. ANS: B A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases (see Table 19-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE
- 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.” c. 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. ANS: A, C, D
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ANS: B, C, D, E
(ARDS occurs when an acute pulmonary insult (trauma, gastric acid aspiration, shock, sepsis) damages the alveolar capillary membrane, leading to increased permeability of the pulmonary capillaries and the alveolar epithelium and to pulmonary edema. Gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed, and hyaline membranes lining the distended alveoli. Subjective: Acute onset of dyspnea, apprehension. Inspection: Restlessness; disorientation; rapid, shallow breathing; productive cough; thin, frothy sputum; retractions of intercostal spaces and sternum. Decreased PaO 2 , blood gases show respiratory alkalosis, radiographs show diffuse pulmonary infiltrates, a late sign is cyanosis. Palpation: Hypotension. Auscultation: Tachycardia. Adventitious sounds: Crackles, rhonchi. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
