A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

A) Kyphosis: While kyphosis is an important physical finding that could impact a client's respiratory and musculoskeletal health, it is typically assessed during the general physical examination and postural assessment rather than as part of the anterior chest assessment. Therefore, kyphosis is not directly part of the anterior chest examination, though it could be a factor influencing respiratory mechanics.

B) Gastrointestinal sounds: Gastrointestinal sounds are assessed during the abdominal examination, not the chest examination. The anterior chest exam focuses on respiratory and cardiac assessments, which do not involve auscultating bowel sounds. Hence, gastrointestinal sounds are not part of the chest examination.

C) Heart sounds: Auscultation of heart sounds is a crucial part of assessing the anterior chest, as it helps the nurse evaluate cardiac function. The nurse listens to heart sounds at specific areas on the chest (e.g., aortic, pulmonic, tricuspid, and mitral areas) to identify any abnormalities such as murmurs, arrhythmias, or other issues.

D) Breath sounds: Breath sounds are an essential component of the chest assessment. By auscultating the lungs, the nurse can identify normal or abnormal breath sounds, such as wheezes, crackles, or decreased breath sounds, which may indicate respiratory issues like pneumonia, asthma, or emphysema.

E) Symmetric expansion: Symmetric expansion refers to the even movement of both sides of the chest during inhalation and exhalation. Assessing symmetric chest expansion helps the nurse identify any respiratory abnormalities, such as atelectasis, pneumonia, or other lung pathologies that may cause uneven chest expansion, signaling a potential underlying issue.

A) Inspection of the shape and configuration of the chest during normal breathing:
While inspecting the shape and configuration of the chest can provide important information about potential deformities or abnormalities (such as a barrel chest or scoliosis), it does not directly assess the symmetry of chest expansion. Inspection primarily focuses on the external appearance rather than the physiological movement of the chest wall during respiration. Symmetry of chest expansion requires more than visual observation; it involves assessing the movement of the chest during inhalation and exhalation.

B) Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10:
This technique is the most effective for confirming symmetric expansion of the chest. The nurse places their hands on the patient's back, with the thumbs positioned at the level of T9 or T10, and asks the patient to take a deep breath. As the patient inhales, the nurse assesses the expansion of both sides of the chest by observing whether the thumbs move apart symmetrically. This test directly evaluates the expansion of the lungs and chest wall during respiration and is the most accurate way to assess symmetry.

C) Percussion of the posterior chest to initiate vibration of the lung structures:
Percussion is a technique used to assess the underlying lung tissue and the presence of conditions like pneumonia, fluid accumulation, or air trapping. It does not directly assess the symmetry of chest expansion. While percussion may provide valuable diagnostic information about the lungs, it does not help in determining how evenly the chest is expanding during normal breathing.

D) Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine":
This technique refers to vocal fremitus, where the nurse places their hands on the client's chest while the client repeats "ninety-nine." It helps assess the transmission of sound vibrations through the chest wall, which can be used to detect areas of consolidation or fluid in the lungs. However, it does not directly evaluate the symmetry of chest expansion. The vibration felt on both sides of the chest may be different in cases of lung disease, but this test does not assess the movement of the chest during breathing.