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.

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Correct Answer is A

Explanation

A) The partner places the client's arm above the level of the client's heart:
This action indicates that further instruction is needed. For an accurate blood pressure reading, the arm should be at heart level (approximately at the level of the fourth intercostal space) when taking the measurement. If the arm is placed above the heart, it can result in a falsely low reading. If the arm is positioned below the heart, it can lead to a falsely high reading. The position of the arm is crucial for obtaining an accurate blood pressure measurement.

B) The partner centres the cuff bladder over the client's brachial artery:
This is the correct technique. The cuff bladder should be centered over the brachial artery for accurate readings. Proper cuff placement ensures the best possible measurement and avoids errors in reading due to misplacement.

C) The partner wraps the blood pressure cuff around the client's arm using firm pressure:
This is also correct. The cuff should be wrapped snugly around the upper arm with firm pressure to ensure that it fits properly. If the cuff is too loose or too tight, it may give inaccurate readings. However, it should never be excessively tight.

D) The partner checks the instrument gauge to ensure the reading starts at zero:
This is a correct action. Before using a blood pressure cuff, it is important to check that the gauge starts at zero when the cuff is deflated. This ensures the manometer is calibrated properly and provides accurate readings. If the gauge does not start at zero, it should be recalibrated or replaced.

A. Demonstrate that both arteries will be palpated simultaneously to compare amplitude B. Instruct the client take a deep breath and "hold" while the nurse briefly auscultates C. Discuss that a light will be directed at the neck to observe for pulsations of the artery D. Show the client the diaphragm of the stethoscope that will be placed on the neck

Correct Answer is B

Explanation

A) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

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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.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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