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?

Inspection of the shape and configuration of the chest during normal breathing

Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

Percussion of the posterior chest to initiate vibration of the lung structures

Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine’’

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

A) A heart murmur is a high-pitched sound caused by a narrowing of a heart valve:
While it's true that a narrowing of a heart valve (stenosis) can cause a murmur, the description of a heart murmur as a "high-pitched sound" due to this narrowing is overly specific and does not fully explain what a murmur is. A murmur is not always high-pitched, and it is caused by turbulent blood flow, which may occur for various reasons beyond just valve stenosis.

B) A heart murmur is an extra sound heard from blood entering a rigid heart chamber:
This description is somewhat inaccurate. While murmurs can result from turbulent blood flow through the heart chambers or valves, the idea that murmurs are "extra sounds from blood entering a rigid heart chamber" is misleading. A murmur occurs when there is turbulent blood flow, which can happen in both rigid and non-rigid chambers. The key point is that it's the turbulent flow, not just rigidity, that causes the sound.

C) A heart murmur is a sound generated by inflammation around the heart muscle:
This is incorrect. Inflammation around the heart muscle, such as in pericarditis, can cause chest pain or other symptoms but does not generate a heart murmur. A murmur is caused by turbulent blood flow, which can result from various heart valve issues (e.g., stenosis, regurgitation) or defects in the heart's structure (e.g., septal defects), not from inflammation around the heart muscle.

D) A heart murmur indicates turbulent blood flow through a valve in the heart:
This is the most accurate description. A heart murmur is typically caused by turbulent or irregular blood flow through a heart valve. This can occur for several reasons, such as valve stenosis (narrowing), valve regurgitation (leakage), or congenital heart defects that cause abnormal flow patterns. The turbulent flow disrupts the normal laminar (smooth) blood flow, creating the characteristic sound that can be heard with a stethoscope. Murmurs can vary in timing, pitch, and intensity depending on the nature of the flow disturbance.

A. Obtain a threat culture for possible streptococcal (strep) infection B. Continue with the assessment, looking for any other abnormal findings C. Refer the client to their primary provider D. No response is needed, this appearance is normal for the tonsils

Correct Answer is D

Explanation

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture for streptococcal infection is generally warranted when there are signs and symptoms of a bacterial infection, such as a sore throat, fever, exudate on the tonsils, or swollen lymph nodes. The description provided—involuted, granular tonsils with deep crypts—is a normal, age-related finding and not indicative of an infection. Therefore, obtaining a throat culture is unnecessary unless additional clinical signs of infection are present.

B) Continue with the assessment, looking for any other abnormal findings:
While it is always important to complete a thorough assessment and look for other abnormal findings, the specific characteristics described (involuted, granular tonsils with deep crypts) are normal, particularly in adults. This is a common finding and does not require further investigation unless accompanied by other symptoms such as pain, swelling, or visible pus, which would warrant a closer look.

C) Refer the client to their primary provider:
Referral to a primary provider is generally recommended if there are significant concerns about the tonsils, such as persistent swelling, pain, or signs of infection. However, the description provided does not suggest a pathological issue; these characteristics are typically considered normal in adults. Referral would only be necessary if additional concerning symptoms were present, such as fever, difficulty swallowing, or changes in voice.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Involuted (shrunken), granular tonsils with deep crypts are a normal, age-related finding, especially in adults. Over time, the tonsils tend to shrink and develop more pronounced crypts (pockets). This is part of the natural aging process and is not usually a sign of pathology. These tonsil changes are often seen in individuals who have had repeated infections or as part of the natural aging process.

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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?

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Naxlex Comprehensive Predictor Exams

A client was recently diagnosed with a heart murmur and is asking the nurse for more information. How should the nurse describe to the client about what a heart murmur is?

Correct Answer is D

Explanation

A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. The nurse should recognize that which of the following is the correct response to these findings?

Correct Answer is D

Explanation

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