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.)

Kyphosis

Gastrointestinal sounds

Heart sounds

Breath sounds

Symmetric expansion

Answer and Explanation

Correct Answer : C,D,E

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Dysphagia:
Dysphagia, or difficulty swallowing, is a common issue in clients who have had a stroke, particularly when there is facial drooping or weakness on one side of the face, which can affect the muscles involved in swallowing. A stroke can cause motor impairment, affecting the coordination and strength required for effective swallowing. This condition increases the risk of aspiration (food or liquid entering the airway), which can lead to respiratory complications such as pneumonia. It is crucial to assess for dysphagia in stroke patients and provide appropriate interventions, such as speech therapy and modified diets, to ensure safe swallowing.

B. Rhinitis:
Rhinitis, which refers to inflammation of the nasal passages causing symptoms like congestion, sneezing, and runny nose, is not directly related to stroke. Although rhinitis can be caused by allergies, infections, or environmental irritants, it is not a typical finding following a stroke. The presence of facial drooping on one side is more suggestive of a neurological issue affecting motor control, rather than an issue with the nasal passages or upper respiratory system.

C. Xerostomia:
Xerostomia, or dry mouth, can occur for various reasons, such as medication side effects or dehydration, but it is not a primary concern directly associated with stroke-induced facial drooping. While facial nerve dysfunction can affect salivation (since the facial nerve helps control the salivary glands), dysphagia and facial drooping are more immediate concerns for stroke patients. Xerostomia may occur in some cases, but it is not as directly linked to stroke as dysphagia is.

D. Epistaxis:
Epistaxis, or nosebleeds, is not a typical complication of stroke and is not associated with facial drooping. While certain factors like dry air, medications (e.g., anticoagulants), or trauma could cause nosebleeds, they are not common findings directly related to a stroke. The focus should be on potential neurological deficits, such as difficulty swallowing, impaired speech, or weakness, rather than epistaxis.

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles B. Contraction the atria at the beginning of diastole can be felt as a click C. The ventricles contract during systole and attempt to push against closed atria D. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole

Correct Answer is A

Explanation

A) The atria contract toward the end of diastole and push the remaining blood into the ventricles:
This is the correct definition of the atrial kick. The atrial kick refers to the contraction of the atria just before the ventricles contract, which occurs late in diastole. During this phase, the atria contract to push the remaining blood into the ventricles, ensuring that the ventricles are as filled as possible before the next ventricular contraction. This action contributes to about 20–30% of the ventricular filling, especially important in situations where the heart rate is fast, as there may be less time for passive filling during diastole.

B) Contraction of the atria at the beginning of diastole can be felt as a click:
This statement is incorrect. Atria contract at the end of diastole, not the beginning. The atrial contraction is not typically felt as a "click." If there is a "click" sound, it could indicate an abnormal heart valve sound, such as from a mitral valve prolapse, rather than the normal atrial contraction. The atrial kick itself is not associated with any audible click but may be heard as part of the S4 heart sound, especially in conditions with stiff ventricles (such as hypertension or heart failure).

C) The ventricles contract during systole and attempt to push against closed atria:
This is not an accurate description of the atrial kick. During systole, the ventricles contract and push blood into the aorta and pulmonary artery through the open semilunar valves, not against the atria. The atrial kick is a part of diastole, not systole, and involves the atria pushing blood into the ventricles, not the ventricles pushing against the atria.

D) Atrial kick is the pressure exerted against the atria as the ventricles contract during systole:
This description is incorrect. The atrial kick occurs when the atria contract near the end of diastole, not during systole. During systole, the ventricles contract and pump blood out of the heart, but this is not related to the atrial kick. Instead, the atrial kick is the contribution of atrial contraction to the final phase of ventricular filling, just before the ventricles contract.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?

Correct Answer is A

Explanation

A nurse reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

Correct Answer is A

Explanation

A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

A nurse is discussing the blood flow pattern of the heart. The nurse should recognize which of the following as the accurate blood flow pattern of the heart?

A nurse is reviewing the sequence of the cardiac cycle. The nurse recognizes that the electrical stimulus of the cardiac cycle follows which sequence?

A nurse is caring for a client complaining of throbbing pain in the face, teeth, and cheeks. Upon palpation, the nurse notes swollen turbinates and a purulent discharge the nose. The nurse should recognize that the client's symptoms best correlate with which problem?

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner should indicate that further instruction is needed?

A nurse is auscultating the lungs of a client and hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. How should the nurse interpret these findings?

A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?